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Medicare Advantage · Local PPO
Blue Cross Blue Shield of Michigan
Plan year 2026

Medicare Plus Blue Essential (PPO) H9572-004

4.5 · 2026 Star Rating · source: CMS · Ratings are updated annually
Monthly premium
$25
+ your Part B premium
Max out-of-pocket
$6,250
in-network annual cap
Primary care
$0
per visit copay
Specialist
$45
per visit
This plan includes a Part B giveback, which lowers what you pay for your Medicare Part B premium by up to $9.2 a month. Depending on how you pay Part B, the reduction may appear in your Social Security payment or on your Part B bill. That is up to $110.4 a year. Processing can take time; confirm the amount and timing with the plan.

Your costs at a glanceIn-network, for the 2026 plan year

Rx deductible
$150
Inpatient hospital
Days 1-7: $350/day, Days 8-90: $0/day
no limit on covered hospital days
Inpatient mental health
Days 1-7: $300/day, Days 8-90: $0/day
Outpatient surgery
$125
–$350
Emergency room
$130
Urgent care
$50

What's included, and what it's actually worth4 benefits included. Tap any card for the detail

Part B giveback

$9.20/month
DetailsThis plan includes a Part B giveback, which lowers what you pay for your Medicare Part B premium by up to $9.20 a month.
Processing can take time; confirm the amount and timing with the plan.

Dental

$950/yr allowance
Annual max$950/yr allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.
See more details about this plan
Doctor Visits: PCP$0 copay
In-network$0 copay per visit
Doctor Visits: Specialist$45 copay
In-network$45 copay per visit
Inpatient Hospital$350/day, days 1–7
In-networkDays 1-7: $350/day, Days 8-90: $0/day
Benefit limitNone — additional covered days are unlimited
Outpatient Surgery$125–$350
In-network$125–$350 per procedure
Mental HealthDays 1-7: $300/day, Days 8-90: $0/day
Inpatient psychiatricDays 1-7: $300/day, Days 8-90: $0/day
VisionRoutine vision benefit
DetailsRoutine vision benefit
This is a supplemental benefit with plan-specific limits. See plan documents for details.
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
$0
Preferred Generic
Tier 2
$5
Generic
Tier 3
20%
Preferred Brand· after deductible
Tier 4
25%
Non-Pref Brand· after deductible
Tier 5
31%
Specialty· after deductible

Our take

Where this plan shines

See your primary doctor for $0.
Highly rated by CMS (4.5 stars).

Things to know before you enroll

This plan’s out-of-pocket maximum is above the national median.
Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits (PDF)
Download the plan's official Summary of Benefits document
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (855)425-7720 (TTY: 711) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Every year, Medicare evaluates plans based on a 5-star rating system. Star ratings are based on 2026 data and may change annually.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

The standard Part B premium for 2026 is $202.90. Monthly reduction on Medicare Part B premium varies and may be subject to processing delays and may not be immediate.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
  2. The Pocket Protector is not connected with or endorsed by the United States government or the federal Medicare program.

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