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2011 Medicare Plus Blue PPOSM enrollment

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Enroll now

It's easy to enroll in our individual Medicare Plus Blue PPO plan. Enroll now, or use the Medicare Plus Blue PPO enrollment form to sign up. Refer to Summary of Benefits for a description of the plan. For detailed benefit information, refer to Evidence of Coverage.

Download Enrollment Form Below

Please select the form below. You will be presented with the enrollment form for Medicare Plus Blue PPO. Fill out the form and be sure to make a copy of it to save for your records. Put the form in a stamped 9" x 11" envelope and return to us at:

Blue Cross Blue Shield of Michigan
Medicare Plus Blue PPO Enrollment
P.O. Box 3817
Southfield, MI 48037-3817
Fax: 248-448-4041

Plan Enrollment Form
Medicare Plus Blue PPO plan overview brochure Pre-enrollment booklet (PDF 357K)
Medicare Plus Blue PPO enrollment form Enrollment Form (PDF 264K)
Automatic deduction form Deduction Form (PDF 41K)

For more information contact Medicare Plus Blue PPO at 1-877-469-2583 (TTY users call 1-800-481-8704) from 8 a.m. to 8 p.m. seven days a week.

Also, you can visit our Member Services Locations.

Please contact Medicare Plus Blue at 1-877-469-2583 (1-877-4My-BLUE), (TTY users should call 1-800-481-8704), if you need information in another format or to be referred to our foreign language line. Call center hours are seven days a week, from 8 a.m. to 8 p.m. Eastern time.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO through the Centers for Medicare and Medicaid Services Online Enrollment Center, located at www.medicare.gov, beginning Nov. 15, 2010.

Please remember:

To Complete an Enrollment Form We Sent You

If you received an enrollment form in the mail from us, please fill it out completely. Be sure to check which plan you want to enroll in and to save a copy for your records. Put the completed enrollment form (do not fold it) in the 9" x 11" postage-paid envelope we sent you and mail it back to us. If you have not received this enrollment form, you can call us for one or download the appropriate enrollment form from this website.

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People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about the Extra Help program, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days per week. TTY users should call 1-877-486-2048.

Important information about these plans

Medicare Plus Blue PPOSM is a health plan with a Medicare contract.

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.

Premiums vary by county. You must continue to pay your Medicare Part B premium.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on Jan. 1, 2013.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. To learn more about enrollment periods, please contact Member Services.