Blue Medicare PPO Enhanced (PPO)

Medicare Advantage Plan for North Carolina

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderBlue Cross Blue Shield of North Carolina
Plan IDH3404-3-2
CMS Rating1
Plan TypePPO
Annual Deductible$0.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$10,000 In and Out-of-network $6,700 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$81.90
Monthly Health Plan Premium
$31.70

Benefits

Service
Cost
Inpatient hospital coverage
In-Network:
$300 for days 1 through 6
$0 for days 7 through 90
$0 for days 91 and beyond
Out-of-Network:
40% for days 1 and beyond
Outpatient hospital coverage
In-Network:
$275 per visit
Out-of-Network:
40% per visit
Doctor visits
Primary:
In-Network:
$20 per visit
Out-of-Network:
40% per visit
Specialist:
In-Network:
$50 per visit
Out-of-Network:
40% per visit
Preventive care
In-Network:
$0 copay
Out-of-Network:
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$65 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
In-Network:
20%
Out-of-Network:
40%
Lab services:
In-Network:
20%
Out-of-Network:
40%
Diagnostic radiology services (e.g., MRI):
In-Network:
20%
Out-of-Network:
40%
Outpatient x-rays:
In-Network:
20%
Out-of-Network:
40%
Mental health services
In-Network:
$270 for days 1 through 6
$0 for days 7 through 90
Out-of-Network:
40% for days 1 through 190
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
40%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
40%
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
40%
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
40%
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 60
$0 for days 61 through 100
Out-of-Network:
40% for days 1 through 100
Rehabilitation services
Occupational therapy visit:
In-Network:
$40
Out-of-Network:
40%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
40%
Ambulance
In-Network:
$250
Out-of-Network:
$250
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$50
Out-of-Network:
40%
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
40% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
40% per item
Diabetes supplies:
In-Network:
$0 copay
Out-of-Network:
40% per item
Wellness programs (e.g., fitness, nursing hotline)
Not covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
40%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
40%

Coverage Area for Blue Medicare PPO Enhanced (PPO)

StateNorth Carolina
CountyCabarrus

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$3 copay$15 copay$3 copay
Tier 2: Non-Preferred Generic$6 copay$20 copay$6 copay
Tier 3: Preferred Brand Name$37 copay$47 copay$37 copay
Tier 4: Non-Preferred Brand Name45% coinsurance50% coinsurance45% coinsurance
Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$9 copay$45 copay$9 copay
Tier 2: Non-Preferred Generic$18 copay$60 copay$18 copay
Tier 3: Preferred Brand Name$111 copay$141 copay$111 copay
Tier 4: Non-Preferred Brand Name45% coinsurance50% coinsurance45% coinsurance
Tier 5: Specialty Tier

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care management
Not Rated
Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physician Finder

Physicians that accept Blue Medicare PPO Enhanced (PPO) for North Carolina

/
KILBANE, SHEILA
8605 CLIFF CAMERON DR
CHARLOTTE, NC 28269
ASHENFARB, STEVEN
1308 BEDLINGTON DR
CHARLOTTE, NC 28269
SALMON, MARY
4920 OLD FOX TRL
CHARLOTTE, NC 28269
SHOLAR, VERONICA
10616 METROMONT PKWY STE 102
CHARLOTTE, NC 28269
MOORE, MARGARET
3403 LINDEN BERRY LN
CHARLOTTE, NC 28269
SMITH, TERRI
10220 PROSPERITY PARK DR STE 300
CHARLOTTE, NC 28269
MORGAN, AMY
10220 PROSPERITY PARK DR STE 300
CHARLOTTE, NC 28269
LEWIS, ANGELA
4045 AMBER LEIGH WAY DR
CHARLOTTE, NC 28269
KALLEBERG, KARI
5727 PROSPERITY CROSSING DR.
CHARLOTTE, NC 28269
INDUSTRICARE
10430 B HARRIS OAKS BLVD
CHARLOTTE, NC 28269
KNUTSON, HEATHER
5727 PROSPERITY CROSSING DR.
CHARLOTTE, NC 28269
TAKAHASHI, REBECCA
5727 PROSPERITY CROSSING DR.
CHARLOTTE, NC 28269
LESTER, SUSAN
5727 PROSPERITY CROSSING DRIVE
CHARLOTTE, NC 28269
BEAN, MICHAEL
10220 PROSPERITY PARK DR STE 300
CHARLOTTE, NC 28269
SHULSTAD, ANDREW
10220 PROSPERITY PARK DR STE 300
CHARLOTTE, NC 28269
WOLYNIAK, JOSEPH
7004 SMITH CORNERS BLVD
CHARLOTTE, NC 28269
CHARLOTTE SPORTS MEDICINE INSTITUTE, P.A.
10616 METROMONT PKWY
CHARLOTTE, NC 28269
RACZ, LEAH
10616 METROMONT PKWY
CHARLOTTE, NC 28269
DUMOND, SARA
6401 STARGAZE LN
CHARLOTTE, NC 28269
ROCKMAN, ERIN
3403 LINDEN BERRY LN
CHARLOTTE, NC 28269
PIEDMONT THERAPY SERVICES, INC.
8810 LAUREL RUN DR
CHARLOTTE, NC 28269
MADSEN, CHRISTIAN
9200 WEST WT HARRIS BOULEVARD
CHARLOTTE, NC 28269
Details
SHEILA KILBANE, MD
Phone Number
(704) 548-9947
Office Locations
8605 CLIFF CAMERON DR
CHARLOTTE, NC 28269
8605 CLIFF CAMERON DR CHARLOTTE NC, 28269

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