Medicare Plan Lookup Official CMS data · Contract Year 2026
CMS 2026 data

2026 Medicare plan code

H9572-003-004

Medicare Plus Blue Assure (PPO) · Blue Cross Blue Shield of Michigan · Region 4

Compact plan code: H9572003004

2026

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2026 plan record

Medicare Plus Blue Assure (PPO)

H9572-003-004 Region 4 Local PPO
Open in quick lookup
01

In-network

Inpatient hospital

Days 1–7 $100 / day
Days 8–90 $0 / day
Total of listed copays · 7 charged days $700
02

Emergency transport

Ambulance

Ground · in-network$250 copay
Air · in-network$250 copay
03

Emergency services

Emergency room

$130 copay

Waived if admitted

04

Medical maximum

Maximum out-of-pocket

In-network$4,000
Combined in + out$6,200
05

Skilled care at home

Home health

In-networkNo cost share reported
Out-of-network30% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$99.90 / month
Consolidated C + D$209.50 / month

Source trail

Official CMS, Contract Year 2026

Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release. Quick-reference values should be confirmed in current official plan documents.

PBP benefits ↗ Landscape data ↗

Same CMS contract

H9572-001-001 Medicare Plus Blue Signature (PPO) Region 1 · Local PPO H9572-001-002 Medicare Plus Blue Signature (PPO) Region 2 · Local PPO H9572-001-003 Medicare Plus Blue Signature (PPO) Region 3 · Local PPO H9572-001-004 Medicare Plus Blue Signature (PPO) Region 4 · Local PPO H9572-001-006 Medicare Plus Blue Signature (PPO) Region 6 · Local PPO H9572-002-001 Medicare Plus Blue Vitality (PPO) Region 1 · Local PPO H9572-002-002 Medicare Plus Blue Vitality (PPO) Region 2 · Local PPO H9572-002-003 Medicare Plus Blue Vitality (PPO) Region 3 · Local PPO

About this code

What H9572-003-004 identifies

H9572-003-004 is a Contract Year 2026 Medicare plan segment code. The compact form H9572003004 refers to the same normalized contract, plan, and segment shown on this page.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.