<Medicare Plus BlueSM PPO (Essential, Vitality, Signature and Assure)>
Monthly Plan Premium for People who get Extra Help from Medicare
to Help Pay for their Prescription Drug Costs
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs,
your monthly plan premium will be lower than what it would be if you did not get extra help
from Medicare. The amount of extra help you get will determine your total monthly plan
premium as a member of our plan.
This table shows you what your monthly plan premium will be if you get extra help.
Note: The premiums vary by the county in which you permanently reside.
(Rates are based on the use and cost of health care services in each region.)
1. Locate the region/county in which you permanently reside.
2. Look at the plan options to find your monthly premium rate.
Region with Counties
Your level of
extra help
Region 1:
Allegan, Barry, Ionia, Kalamazoo,
Mason, Muskegon, Newaygo,
Oceana and Ottawa counties
100%
$0.00
$17.30
$96.80
$176.80
75%
$5.20
$24.50
$105.40
$185.40
50%
$10.50
$31.60
$113.90
$193.90
25%
$15.70
$38.80
$122.50
$202.50
100%
$0.00
$53.80
$146.80
$236.80
75%
$6.40
$62.40
$155.40
$245.40
50%
$12.70
$70.90
$163.90
$253.90
25%
$19.10
$79.50
$172.50
$262.50
Region 2:
Berrien, Branch, Calhoun, Eaton,
Gratiot, Hillsdale, Ingham,
Jackson, Monroe, Montcalm, St.
Joseph and Van Buren counties
Monthly Premium You Pay for
<Medicare Plus Blue PPO Plan>*
<Essential> <Vitality> <Signature>
<Assure>
Medicare Plus Blue is a PPO plan with a Medicare contract.
Enrollment in Medicare Plus Blue depends on contract renewal.
H9572_C_17LISPremChrt NM 09142016
Region with Counties
Your level of
extra help
Monthly Premium You Pay for
<Medicare Plus Blue PPO Plan>*
<Essential> <Vitality> <Signature>
<Assure>
Region 3:
Alcona, Alger, Alpena, Arenac,
Baraga, Bay, Charlevoix,
Cheboygan, Chippewa, Clare,
Crawford, Gladwin, Huron, Iosco,
Kalkaska, Keweenaw, Luce,
Mackinac, Montmorency,
Ogemaw, Ontonagon, Oscoda,
Presque Isle, Roscommon,
Saginaw, Sanilac, Schoolcraft,
Shiawassee and Tuscola counties
100%
$0.00
$71.80
$146.80
$279.80
75%
$7.60
$80.40
$155.40
$288.40
50%
$15.20
$88.90
$163.90
$296.90
25%
$22.90
$97.50
$172.50
$305.50
Region 4:
Antrim, Benzie, Cass, Clinton,
Delta, Dickinson, Emmet,
Genesee, Gogebic, Grand
Traverse, Houghton, Iron,
Isabella,
Kent, Lake, Lapeer,
Leelanau, Lenawee, Livingston,
Manistee, Marquette, Mecosta,
Menominee, Midland,Missaukee,
Osceola, Otsego, St. Clair and
Wexford counties
100%
$0.00
$51.80
$146.80
$229.80
75%
$7.60
$60.40
$155.40
$238.40
50%
$15.20
$68.90
$163.90
$246.90
25%
$22.90
$77.50
$172.50
$255.50
Region 6:
Macomb, Oakland, Washtenaw
and Wayne counties
100%
$0.00
$76.80
$139.80
$279.80
75%
$6.40
$85.40
$148.40
$288.40
50%
$12.70
$93.90
$156.90
$296.90
25%
$19.10
$102.50
$165.50
$305.50
*This does not include any Medicare Part B premium you may have to pay.
[Plan sponsor must ensure that the premiums displayed in the table above are accurate and
therefore reflect the premiums for beneficiaries who receive extra help as displayed on HPMS.
100% premiums should be reduced by the de minimis amount for de minimis plans.]
[MA-PDs must insert the following sentence: <Medicare Plus Blue PPO’s> premium includes
coverage for both medical services and prescription drug coverage.]
If you aren’t getting extra help, you can see if you qualify by calling:
 1-800-MEDICARE or TTY users call 1-877-486-2048 (24 hours a day/7 days a week),
 Your State Medicaid Office, or
 The Social Security Administration at 1-800-772-1213. TTY users should call
1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.
If you have any questions, please call <Customer> Service at <1-877-241-2583>, (TTY: <711>)
from <8 a.m. to 9 p.m. Eastern time, Monday through Friday (October 1 – February 14, 8 a.m. to
9 p.m., seven days a week).>
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part
B premium.