Plan Details
Costs and Other Important Information
Benefits
$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
$275 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
$0 copay
Out-of-Network:
$0 copay
$80 per visit (always covered)
Urgent care:
$65 per visit (always covered)
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%
$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%
$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
In-Network:
$40
Out-of-Network:
40%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
40%
$250
Out-of-Network:
$250
In-Network:
$50
Out-of-Network:
40%
Routine foot care:
Not covered
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%
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
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept Blue Medicare PPO Enhanced (PPO) for North Carolina