H9572-008 — Medicare Plus Blue Giveback (PPO) — 2026 Medicare Advantage Prescription Drug Plan
Blue Cross Blue Shield of Michigan
Plan ID: H9572-008 · Contract: H9572
Use this Medicare plan ID to verify you are comparing the exact 2026 plan before checking benefits, county availability, drug coverage, provider networks, and costs.
How this PPO works
A PPO generally lets you use in-network or out-of-network providers that accept the plan, but out-of-network care can cost more. You usually do not need a referral for specialists. Always confirm that a provider accepts this specific plan.
Monthly Premium
$0/mo
This is the plan premium shown in CMS data. You must continue paying your Medicare Part B premium unless another program pays it for you.
Medical Deductible
Not available
CMS data does not list a medical deductible for this plan. This does not mean the cost is $0.
Drug Deductible
$150
Max Out-of-Pocket
$9,250
Common Medical Cost Sharing
A copay is a fixed dollar amount. Coinsurance is a percentage of the allowed cost. The amount you owe can depend on the service, provider, network, and plan rules.
Not available in the CMS data
Primary Care
Not available in the CMS data
Specialist
$115 copay
Emergency Room
$0 copay
Urgent Care
Supplemental Benefits
Benefit Details
Preventive Dental
Coverage included; review plan details for limits
Vision - Eye Exams
$0 copay
Hearing Exams & Aids
Coverage included; review plan details for limits
Meals
Coverage included; review plan details for limits
Transportation
$40 copay
Telehealth
$90 copay
Drug Coverage Summary
Drug Deductible
$150
Drug Premium
$0/mo
This plan includes Part D prescription drug coverage. Drug costs depend on which tier your medications fall under. Use our comparison tool to estimate your specific drug costs.
Medical Benefits
Inpatient Hospital
In-network: Not available in the CMS data
Emergency Room
In-network: $115 copay
Urgent Care
In-network: $0 copay
Primary Care
In-network: Not available in the CMS data
Specialist
In-network: Not available in the CMS data
Outpatient Hospital
In-network: Not available in the CMS data
Dental - Preventive
In-network: Not available in the CMS data
Vision - Eye Exams
In-network: $0 copay
Hearing - Exams & Aids
In-network: Not available in the CMS data
Counties Served (27)
Michigan
Data Source and Verification
Sources: Centers for Medicare & Medicaid Services (CMS) public-use data. The following CMS pages provide the source files and their documentation:
- Plan premiums and service areas — CMS Landscape files
- Plan Benefit Package (PBP) benefits data
- Monthly Part D formulary and pharmacy network files
- Part C and D performance data — Star Ratings
Data vintage: 2026 plan-year data. CMS may revise files during the year.
Verify before enrolling: Confirm premiums, benefits, drugs, pharmacies, providers, eligibility, and service area with Medicare.gov Plan Compare or the plan. Read our methodology and editorial policy, or visit the Medicare plan FAQ.
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