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Blue Medicare PPO Enhanced (PPO) - H3404-003-002
$53.00
Monthly Premium
Blue Medicare PPO Enhanced (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H3404-003-002
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$53.00
Monthly Premium
North Carolina Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.
Learn more about North Carolina Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $53.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $100.00 |
| Out-of-pocket maximum | $6,300.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 40% |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 40% Specialist copay also applies to acupuncture for chronic Low Back Pain (cLBP) |
| Inpatient hospital care | In-Network: Acute Hospital Services: $350 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $50 Maximum Plan Benefit of $100,000 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $130 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 48 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation $250 Maximum Plan Benefit of $100,000 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250 Air Ambulance: Copayment for Air Ambulance Services $250 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Blue Medicare PPO Enhanced (PPO) covers a range of additional benefits. Learn more about Blue Medicare PPO Enhanced (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $25 Copayment for Medicare-covered Lab Services $0 to $5 Cost sharing will be applied for each service received from each facility each day.Medicare covered diagnostics:Service performed in PCP Office - $0 copayService performed in any other setting - $25 copayDiagnostic colonoscopy: $0 copay Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Copayment for Medicare-covered Therapeutic Radiological Services $0 to $60 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $15 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $350 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $335 Prior Authorization Required for Outpatient Hospital Services $0 for colonoscopy, including diagnostic procedure during which the findings require surgical intervention (for example, removal of polyps). Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $335 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $300 Prior Authorization Required for Ambulatory Surgical Center Services $0 for colonoscopy, including diagnostic procedure during which the findings require surgical intervention (for example, removal of polyps). |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | Out-of-Network: Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 40% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $30 Copayment for Routine Eye Exams $0
Eyewear: Coinsurance for Medicare-Covered Benefits 20% Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0 Copayment for Eyeglass Lenses $0 Copayment for Eyeglass Frames $0 Copayment for Upgrades $0 |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $25 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $499 to $999
|
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Blue Medicare PPO Enhanced (PPO) offers prescription drug coverage, with an annual drug deductible of $100.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $100.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $100.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $100.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
When reviewing North Carolina Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of North Carolina that offer similar benefits at similar or lower prices than the plan above. Call 1-855-861-8771 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
North Carolina Counties Served
- Alexander
- Anson
- Avery
- Beaufort
- Bertie
- Bladen
- Brunswick
- Cabarrus
- Caldwell
- Caswell
- Chowan
- Cleveland
- Columbus
- Cumberland
- Currituck
- Duplin
- Durham
- Edgecombe
- Franklin
- Gates
- Granville
- Halifax
- Henderson
- Hertford
- Hoke
- Johnston
- Jones
- Lee
- Lenoir
- Lincoln
- Madison
- Martin
- Mcdowell
- Mitchell
- Montgomery
- Moore
- Nash
- Northampton
- Orange
- Pender
- Pitt
- Polk
- Richmond
- Robeson
- Rowan
- Rutherford
- Sampson
- Scotland
- Stanly
- Surry
- Swain
- Transylvania
- Union
- Vance
- Wake
- Warren
- Washington
- Watauga
- Wayne
- Wilson
- Yancey
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Healthspring, Wellcare, or Kaiser Permanente.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.