Medicare Plus Blue Signature (PPO) Medicare Advantage Plan H9572-001-3 • 2027
- Monthly Premium
- $168.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $4300.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $200.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 23,917 beneficiaries
Medicare Plus Blue Signature (PPO) Introduction
This Medicare Advantage PPO plan, Medicare Plus Blue Signature, is offered by Blue Cross Blue Shield of Michigan and uses a Preferred Provider Organization (PPO) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $168.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $4300.00. The plan is identified by CMS Plan ID H9572-001-3. The 2027 Part D prescription drug deductible is $200.00.
Plan Benefits
Medicare Plus Blue Signature includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H9572-001-3.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay Out-of-network: 40% coinsurance |
In-network: $0 copay Out-of-network: 40% coinsurance |
| Specialist | In-network: $30 copay Out-of-network: 40% coinsurance |
In-network: $30 copay Out-of-network: 40% coinsurance |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay |
| Telehealth benefit | In-network: $0 copay | In-network: $0 copay |
| Routine chiropractic | In-network: $30 copay Out-of-network: 40% coinsurance |
In-network: $30 copay Out-of-network: 40% coinsurance |
| Fitness benefits | Coming soon | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health education | Not covered | Not covered |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $100-$125 copay Out-of-network: 40% coinsurance |
In-network: $100-$125 copay Out-of-network: 40% coinsurance |
| Lab services | In-network: $0-$30 copay Out-of-network: 40% coinsurance |
In-network: $0-$30 copay Out-of-network: 40% coinsurance |
| Outpatient x-rays | In-network: $35-$125 copay Out-of-network: 40% coinsurance |
In-network: $35-$125 copay Out-of-network: 40% coinsurance |
| Diagnostic tests and procedures | In-network: $0-$125 copay Out-of-network: $0 copay, 40% coinsurance |
In-network: $0-$125 copay Out-of-network: $0 copay, 40% coinsurance |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $130 copay | $130 copay |
| Worldwide emergency care | Coming soon | $130 copay |
| Urgent care | $0-$50 copay | $0-$50 copay |
| Inpatient hospital care | In-network: Tier 1 $250 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $0 and 40% per stay |
In-network: Tier 1 $175 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $0 and 40% per stay |
| Skilled Nursing Facility | In-network: Tier 1 $0 per day for days 1-20 $221 per day for days 21-100 Out-of-network: 40% per stay |
In-network: Tier 1 $0 per day for days 1-20 $218 per day for days 21-100 Out-of-network: 40% per stay |
| Ground ambulance | In-network: $285 copay Out-of-network: $285 copay, 40% coinsurance |
In-network: $285 copay Out-of-network: $285 copay, 40% coinsurance |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $20 copay Out-of-network: 40% coinsurance |
In-network: $20 copay Out-of-network: 40% coinsurance |
| Outpatient group therapy | In-network: $20 copay Out-of-network: 40% coinsurance |
In-network: $20 copay Out-of-network: 40% coinsurance |
| Inpatient psychiatric hospital care | In-network: Tier 1 $250 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $0 and 40% per stay |
In-network: Tier 1 $175 per day for days 1-7 $0 per day for days 8-90 $0 per stay Out-of-network: $0 and 40% per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $35 copay Out-of-network: 40% coinsurance |
In-network: $35 copay Out-of-network: 40% coinsurance |
| Occupational therapy | In-network: $35 copay Out-of-network: 40% coinsurance |
In-network: $35 copay Out-of-network: 40% coinsurance |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
| Durable medical equipment | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
| Prosthetics | In-network: 20% coinsurance Out-of-network: 40% coinsurance |
In-network: 20% coinsurance Out-of-network: 40% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 0%-40% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Dental x-rays | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Cleaning | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Periodontics | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Endodontics | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Restorative services | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Implant services | Not covered | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Contact lenses | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Eyeglass frames only | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Eyeglass lenses only | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 50% coinsurance |
| Eyeglasses (frames & lenses) | Not covered | Not covered |
| Upgrades | Not covered | Not covered |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids | In-network: $495-$1695 copay Out-of-network: $495-$1695 copay |
In-network: $495-$1695 copay Out-of-network: $495-$1695 copay |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | Not covered | Not covered |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | Not covered | Not covered |
| Massage therapy | Not covered | Not covered |
| Home/bathroom safety devices | Not covered | Not covered |
Certain preventive services are covered 100% by Medicare Plus Blue Signature as a Part B benefit.
Prescription Drug Coverage
Medicare Plus Blue Signature includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $15.90 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $15.90 |
| Low-Income Premium Subsidy: | $6.28 |
| Low-Income Premium Subsidy Paid by CMS: | $6.30 |
| Low-Income Subsidy Premium: | $9.60 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $200.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Blue Cross Blue Shield of Michigan starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Medicare Plus Blue Signature may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $5.00 copay | Coming soon |
| Preferred Brand | 20% coinsurance | Coming soon |
| Non-Preferred Drug | 28% coinsurance | Coming soon |
| Specialty Tier | 31% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H9572)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Blue Cross Blue Shield of Michigan
- Website
- Blue Cross Blue Shield of Michigan Plan Page
- Providers
- Blue Cross Blue Shield of Michigan Providers Page
- Formulary
- Blue Cross Blue Shield of Michigan Formulary Page
- Pharmacy
- Blue Cross Blue Shield of Michigan Pharmacy Page
- New Member Health Plan Help
- (855)425-7720
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (855)425-7720
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
Medicare Plus Blue Signature (H9572-001-3) is available in the following locations:
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About Medicare Plus Blue Signature (PPO)
What is the monthly premium for Medicare Plus Blue Signature (PPO)?
The 2027 monthly premium is $168.00. The Medicare Part B premium is paid separately.
What is the in-network MOOP for plan H9572-001-3?
For 2027, the in-network maximum out-of-pocket is $4300.00. The plan pays 100% of covered in-network services beyond this amount.
What is the star rating for plan H9572-001-3 in 2027?
For 2027, plan H9572-001-3 has a CMS star rating of ★0.0 out of 5 stars.
What is the total enrollment for plan H9572-001-3?
Total enrollment is 23,917 beneficiaries based on the latest CMS data.
Is there a Part D deductible for this plan?
The Part D deductible is $200.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Blue Cross Blue Shield of Michigan (official source) | http://www.bcbsm.com/medicare | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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