Medicare Plus Blue Signature (PPO) Medicare Advantage Plan H9572-001-6 • 2027
- Monthly Premium
- $158.00Plus 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 $158.00, 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 H9572-001-6. 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 H9572-001-6.
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 (H9572-001-6) 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)
Is there a monthly premium for this plan in 2027?
For 2027, the monthly premium is $158.00. Medicare Part B premiums apply in addition to this amount.
What is the in-network MOOP for plan H9572-001-6?
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 CMS star rating for this plan?
CMS rates this plan at ★0.0 out of 5 stars for 2027.
What is the total enrollment for plan H9572-001-6?
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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Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.