2025 Medicare Plus BlueSM PPO Vitality
This Blue Cross Blue Shield of Michigan plan offers great coverage at an affordable price. You'll pay less for office visits, have a lower out-of-pocket maximum and access to doctors without a referral.
NETWORK SIZE
MONTHLY PREMIUM
$
Medical deductible
$0
$0.00 monthly payment for 48002
In-network services: $0
Out-of-network services: $0
$0
In-network services: $5,000
Combined in- and out-of-network services: $6,700
Optional supplemental benefits don't count toward your out-of-pocket maximum.
You pay $0.
You pay $30.
You pay $0-$50.
Copays start at $0 for certain generic drugs filled at a preferred network pharmacy. Some drugs may cost more if you choose a pharmacy in our standard network
See if this plan covers your medication. Find your prescription (PDF).
All benefits required by Original Medicare and more, including:
• $0 telehealth visits for primary care and behavioral health
• Advantage Dollars quarterly allowance of $50 for over-the-counter drugs, groceries (for qualified members) and health products
• Worldwide emergency, urgent care and transportation coverage
• Meals benefit following hospital discharge for qualifying members
• One round trip per calendar year to an Annual Physical Exam within the state of Michigan
• Transportation benefit for certain counties following hospital discharge
• SilverSneakers® fitness program
• Coverage for ambulance services not requiring transportation
• Mobile crisis and crisis stabilization for behavioral health for certain counties
• Coverage while traveling outside of Michigan with the nationwide network of Blue Plan Providers (PDF).
This is a PPO plan. PPO stands for preferred provider organization. It's a group of health care professionals that provide services to members. You can choose the doctors you want to see, but pay less when you see a doctor in our network. Find a doctor in this plan's network.
Includes services such as:
• Welcome to Medicare exam
• Personalized prevention plan services
• Bone mass measurement
• Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
• Immunizations (including flu, pneumonia and Hepatitis B vaccines)
• Screening mammograms
• Pap smears
• Behavioral counseling to reduce alcohol misuse
• Behavioral therapy for cardiovascular disease and obesity
You pay $0
Primary care physician: $0 copay.
Specialists: You pay a $30 copay.
You pay 40% of the cost.
Medical: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
Ambulatory surgical center: You pay $0-$125.
Hospital: You pay $150-$220.
You pay 40% of the cost.
Days 1-7: You pay a $250 copay per day.
Days 8-90: You pay $0.
Days 90 and beyond: You pay $0.
You pay 40% of the cost.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
Days 1-20: You pay a $0 copay per day.
Days 21-100: You pay a $214 copay per day.
You pay 40% of the cost.
You pay a $0-$50 copay.
You pay a $125 copay.
You pay a $50 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $125 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $325 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay 0%-20% of the cost.
You pay 0%-40% of the cost.
Emergency: You pay a $325 copay.
Emergency: You pay a $325 copay.
Non-emergency: You pay 40% of the cost.
Spinal manipulation: You pay a $15 copay.
Routine care: You pay a $30 copay.
X-rays, one set per year: You pay a $35 copay.
You pay 40% of the cost.
You pay a $30 copay.
You pay 40% of the cost.
Includes individual and group therapy visits.
You pay a $20 copay.
You pay 40% of the cost.
You pay a $40 copay.
You pay 40% of the cost.
You pay a 20% of the cost.
You pay 40% of the cost.
Commonly prescribed generic versions of brand medications. You’ll pay the least for these drugs at the pharmacy.
Preferred pharmacy: You pay $0.
Standard pharmacy: You pay $5.
Although you’ll pay more at the pharmacy for these generic drugs, they're more cost-effective than brand medications.
Preferred pharmacy: You pay $11.
Standard pharmacy: You pay $20.
Brand drugs that aren’t available yet as a generic.
Preferred pharmacy: You pay $42.
Standard pharmacy: You pay $47.
Because there are alternatives for the drugs in this tier, you’ll pay more for them at the pharmacy.
Preferred pharmacy: You pay 50% of the cost.
Standard pharmacy: You pay 50% of the cost.
Specialty drugs are used to treat complex conditions like cancer and multiple sclerosis. Although they can be generic or brand, they usually need special handling and approval. You may have to order them through a specialty pharmacy.
Preferred pharmacy: You pay 33% of the cost.
Standard pharmacy: You pay 33% of the cost.
Generic drugs: You pay a $0 copay.
Other drugs: You pay a $0 copay.
The benefit provides a $1,500 annual maximum for combined in-network and out-of-network dental services per calendar year.
This plan covers the following dental services for $0 copay in-network and 50% coinsurance out-of-network (frequencies vary):
• Two oral exams per calendar year
• Two routine cleanings per calendar year
• Up to four bitewing X-rays or up to six periapical films every other calendar year
• Fluoride treatments one time per calendar year
• Brush biopsies
• Resin and amalgam fillings
• Crowns
• Crown repairs
• Root canals
• Deep cleanings
• Extractions
• Oral surgery
What's not covered:
• Dental procedures like dentures, onlays and implants (available in optional supplemental benefit buy-up)
Add more dental and vision coverage (PDF) for an additional cost.
This plan covers these benefits:
Vision exams
• One routine eye exam every year for a $0 copay. You can choose any provider from the VSP Choice network.
Glasses and contacts
• We'll pay $150 allowance once per calendar used for elective contact lenses or one pair of frames.
• Eyeglass lenses are covered in full once per year.
• Limitations may apply.
• $0 copay for one pair of Medicare-covered glasses or contact lenses after cataract surgery.
LASIK
• You pay a $30 copay in network for LASIK or RK (radial keratotomy) surgery.
This plan also covers Medicare-covered exams. You'll just have a $30 copay.
Diabetic Retinopathy Eye Exam has a $0 copay.
How this compares:
• This plan offers more vision coverage than Original Medicare.
Add more dental and vision coverage (PDF) for an additional cost.
You pay:
• $0 for one hearing aid fitting and evaluation every three years
• $0 to $30 copay for one routine hearing exam each year
• $0 to $30 copay for Medicare-covered diagnostic hearing exams
• New standard hearing aids every three years. We'll cover up to $750 per ear.
How this compares:
• This plan offers more vision coverage than Original Medicare.
Add more dental and vision coverage (PDF) for an additional cost.
This document lists important features and rules for this plan.
This booklet explains how to use this plan's benefits. It also lists some of the things this plan doesn't cover.
This brochure gives you an overview of all our Medicare Advantage plans to help you compare.
Find a doctor or hospital in this plan's network:
Find a pharmacy in this plan's network:
If you meet certain income and resource limits, you may qualify for help paying for your prescription drug costs through the low-income subsidy.
If you're eligible, see what your monthly premium would be:
The easiest way to enroll in this plan is online. Or call us at 1-888-563-3307. TTY users call 711. You can also print, fill out and mail this paper application.
In-network services: $0
Out-of-network services: $0
$0
In-network services: $5,000
Combined in- and out-of-network services: $6,700
Optional supplemental benefits don't count toward your out-of-pocket maximum.
You pay $0.
You pay $30.
You pay $0-$50.
Copays start at $0 for certain generic drugs filled at a preferred network pharmacy. Some drugs may cost more if you choose a pharmacy in our standard network
See if this plan covers your medication. Find your prescription (PDF).
All benefits required by Original Medicare and more, including:
• $0 telehealth visits for primary care and behavioral health
• Advantage Dollars quarterly allowance of $50 for over-the-counter drugs, groceries (for qualified members) and health products
• Worldwide emergency, urgent care and transportation coverage
• Meals benefit following hospital discharge for qualifying members
• One round trip per calendar year to an Annual Physical Exam within the state of Michigan
• Transportation benefit for certain counties following hospital discharge
• SilverSneakers® fitness program
• Coverage for ambulance services not requiring transportation
• Mobile crisis and crisis stabilization for behavioral health for certain counties
• Coverage while traveling outside of Michigan with the nationwide network of Blue Plan Providers (PDF).
This is a PPO plan. PPO stands for preferred provider organization. It's a group of health care professionals that provide services to members. You can choose the doctors you want to see, but pay less when you see a doctor in our network. Find a doctor in this plan's network.
Includes services such as:
• Welcome to Medicare exam
• Personalized prevention plan services
• Bone mass measurement
• Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
• Immunizations (including flu, pneumonia and Hepatitis B vaccines)
• Screening mammograms
• Pap smears
• Behavioral counseling to reduce alcohol misuse
• Behavioral therapy for cardiovascular disease and obesity
You pay $0
Primary care physician: $0 copay.
Specialists: You pay a $30 copay.
You pay 40% of the cost.
Medical: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
Ambulatory surgical center: You pay $0-$125.
Hospital: You pay $150-$220.
You pay 40% of the cost.
Days 1-7: You pay a $250 copay per day.
Days 8-90: You pay $0.
Days 90 and beyond: You pay $0.
You pay 40% of the cost.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
Days 1-20: You pay a $0 copay per day.
Days 21-100: You pay a $214 copay per day.
You pay 40% of the cost.
You pay a $0-$50 copay.
You pay a $125 copay.
You pay a $50 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $125 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $325 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay 0%-20% of the cost.
You pay 0%-40% of the cost.
Emergency: You pay a $325 copay.
Emergency: You pay a $325 copay.
Non-emergency: You pay 40% of the cost.
Spinal manipulation: You pay a $15 copay.
Routine care: You pay a $30 copay.
X-rays, one set per year: You pay a $35 copay.
You pay 40% of the cost.
You pay a $30 copay.
You pay 40% of the cost.
Includes individual and group therapy visits.
You pay a $20 copay.
You pay 40% of the cost.
You pay a $40 copay.
You pay 40% of the cost.
You pay a 20% of the cost.
You pay 40% of the cost.
Commonly prescribed generic versions of brand medications. You’ll pay the least for these drugs at the pharmacy.
Preferred pharmacy: You pay $0.
Standard pharmacy: You pay $5.
Although you’ll pay more at the pharmacy for these generic drugs, they're more cost-effective than brand medications.
Preferred pharmacy: You pay $11.
Standard pharmacy: You pay $20.
Brand drugs that aren’t available yet as a generic.
Preferred pharmacy: You pay $42.
Standard pharmacy: You pay $47.
Because there are alternatives for the drugs in this tier, you’ll pay more for them at the pharmacy.
Preferred pharmacy: You pay 50% of the cost.
Standard pharmacy: You pay 50% of the cost.
Specialty drugs are used to treat complex conditions like cancer and multiple sclerosis. Although they can be generic or brand, they usually need special handling and approval. You may have to order them through a specialty pharmacy.
Preferred pharmacy: You pay 33% of the cost.
Standard pharmacy: You pay 33% of the cost.
Generic drugs: You pay a $0 copay.
Other drugs: You pay a $0 copay.
The benefit provides a $1,500 annual maximum for combined in-network and out-of-network dental services per calendar year.
This plan covers the following dental services for $0 copay in-network and 50% coinsurance out-of-network (frequencies vary):
• Two oral exams per calendar year
• Two routine cleanings per calendar year
• Up to four bitewing X-rays or up to six periapical films every other calendar year
• Fluoride treatments one time per calendar year
• Brush biopsies
• Resin and amalgam fillings
• Crowns
• Crown repairs
• Root canals
• Deep cleanings
• Extractions
• Oral surgery
What's not covered:
• Dental procedures like dentures, onlays and implants (available in optional supplemental benefit buy-up)
Add more dental and vision coverage (PDF) for an additional cost.
This plan covers these benefits:
Vision exams
• One routine eye exam every year for a $0 copay. You can choose any provider from the VSP Choice network.
Glasses and contacts
• We'll pay $150 allowance once per calendar used for elective contact lenses or one pair of frames.
• Eyeglass lenses are covered in full once per year.
• Limitations may apply.
• $0 copay for one pair of Medicare-covered glasses or contact lenses after cataract surgery.
LASIK
• You pay a $30 copay in network for LASIK or RK (radial keratotomy) surgery.
This plan also covers Medicare-covered exams. You'll just have a $30 copay.
Diabetic Retinopathy Eye Exam has a $0 copay.
How this compares:
• This plan offers more vision coverage than Original Medicare.
Add more dental and vision coverage (PDF) for an additional cost.
You pay:
• $0 for one hearing aid fitting and evaluation every three years
• $0 to $30 copay for one routine hearing exam each year
• $0 to $30 copay for Medicare-covered diagnostic hearing exams
• New standard hearing aids every three years. We'll cover up to $750 per ear.
How this compares:
• This plan offers more vision coverage than Original Medicare.
Add more dental and vision coverage (PDF) for an additional cost.
This document lists important features and rules for this plan.
This booklet explains how to use this plan's benefits. It also lists some of the things this plan doesn't cover.
This brochure gives you an overview of all our Medicare Advantage plans to help you compare.
Find a doctor or hospital in this plan's network:
Find a pharmacy in this plan's network:
If you meet certain income and resource limits, you may qualify for help paying for your prescription drug costs through the low-income subsidy.
If you're eligible, see what your monthly premium would be:
The easiest way to enroll in this plan is online. Or call us at 1-888-563-3307. TTY users call 711. You can also print, fill out and mail this paper application.
You can add an optional supplemental package to your Medicare Advantage plan for an additional monthly cost. It offers:
To get help choosing a plan, call 1-866-875-1375. TTY users dial 711.