2018 Blue Medicare PPO Enhanced (PPO) H3404-3-1 in NC from Blue Cross Blue Shield of North Carolina | HealthPocket

Blue Medicare PPO Enhanced (PPO)

$1,176/mo

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Zip Code28269
Applicant10/16/1983 Male
Coverage Start10/18/2018
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderBlue Cross Blue Shield of North Carolina
Plan IDH3404-3-1
Plan Year2018
CMS Rating
Plan TypePPO
Annual Deductible$0.00

What To Know About This Plan
  • This plan has health and drug coverage
  • This plan is available for 2019. see plan

Why We Like This Plan
  • has both Health and Drug Coverage

Costs and Other Important Information

Plan Year2018
Optional Supplemental BenefitsNo
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$67.70
Monthly Health Plan Premium$30.30

Benefits

SERVICECOST
Inpatient hospital coverageIn-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 coverageIn-Network:
$275 per visit
Out-of-Network:
40% per visit
Doctor visitsPrimary:
In-Network:
$20 per visit
Out-of-Network:
40% per visit
Specialist:
In-Network:
$50 per visit
Out-of-Network:
40% per visit
Preventive careIn-Network:
$0 copay
Out-of-Network:
$0 copay
Emergency care/Urgent careEmergency:
$80 per visit (always covered)
Urgent care:
$65 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic 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 servicesIn-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 FacilityIn-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 servicesOccupational therapy visit:
In-Network:
$40
Out-of-Network:
40%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
40%
AmbulanceIn-Network:
$250
Out-of-Network:
$250
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:
In-Network:
$50
Out-of-Network:
40%
Routine foot care:
Not covered
Medical equipment/suppliesDurable 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 drugsChemotherapy:
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

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

60 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$6 copay$30 copay$6 copay
Tier 2: Non-Preferred Generic$12 copay$40 copay$12 copay
Tier 3: Preferred Brand Name$74 copay$94 copay$74 copay
Tier 4: Non-Preferred Brand Name45% coinsurance50% coinsurance45% coinsurance
Tier 5: Specialty Tier
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

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 managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot 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

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

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Racz, Leah
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Ashenfarb, Steven
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Salmon, Mary
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Sholar, Veronica
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Moore, Margaret
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Smith, Terri
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Morgan, Amy
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Lewis, Angela
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Hewat, Kari
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Industricare
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Knutson, Heather
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Takahashi, Rebecca
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Lester, Susan
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Bean, Michael
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Shulstad, Andrew
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Wolyniak, Joseph
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Charlotte Sports Medicine Institute, P.a.
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Dumond, Sara
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Rockman, Erin
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Kilbane, Sheila
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Piedmont Therapy Services, Inc.
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Madsen, Christian
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Leah Racz, P.T.
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  • Phone Number
    (704) 597-7228
  • Office Locations
    10616 Metromont Pkwy
    Charlotte, NC 28269
10616 Metromont Pkwy Charlotte NC, 28269

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