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
$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
$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
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
$0 copay
Out-of-Network:
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$65 per visit (always covered)
$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%
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%
$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
$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%
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
$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
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
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%
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)
| State | North Carolina |
|---|---|
| County | Cabarrus |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
| 30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-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 Name | 45% coinsurance | 50% coinsurance | 45% coinsurance |
| Tier 5: Specialty Tier | 33% coinsurance | 33% coinsurance | 33% coinsurance |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-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 Name | 45% coinsurance | 50% coinsurance | 45% 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
/
Details
Leah Racz, P.T.
Phone Number
(704) 597-7228
Office Locations10616 Metromont Pkwy
Charlotte, NC 28269
