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Blue Medicare PPO Enhanced (PPO) - H3404-003-002

4.5 out of 5 stars* for plan year 2025

$45.00

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.

$45.00

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 extra 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.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$45.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$5,900.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30
Specialist copay also applies to acupuncture for chronic Low Back Pain (cLBP)
Inpatient hospital careIn-Network:

Acute Hospital Services:
$335 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $55
Maximum Plan Benefit of $100,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120
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 $120
Copayment for Worldwide Emergency Transportation $250
Maximum Plan Benefit of $100,000
Ambulance transportationIn-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).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Medicare Covered 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
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
40%
Coinsurance for Medicare Covered Lab Services
40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
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
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 40%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $30
Copayment for Medicare-covered Group Sessions $30
Outpatient services/surgery
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient substance abuse care
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $75.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $75 every three months
Quitline Program for smoking cessation, the following is available at no cost: 12-wk regimen of combination therapy NRT for up to 2 quit attempts per year NRT (available for 2 quit attempts, total 24 weeks) Monotherapy (1 type of NRT) Gum = 12 wks = 2 boxes shipment 1, 2 boxes shipment 2, 1 box shipment 3 Lozenge = 12 wks = 4 boxes shipment 1, 1 box shipment 2, 1 box shipment 3 Patch = 1 shipment (4 wk supply of 28 patches)* CNRT=combination NRT Patch + Gum 12 wks = 1 patch + 2 boxes gum shipment 1, 1 patch + 1 box gum shipment 2, 1 patch shipment 3 Patch + Lozenge 12 wks = 1 patch + 2 boxes lozenge shipment 1, 1 patch + 1 box lozenge shipment 2, 1 patch shipment 3
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 60
$0 per day for days 61 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.

CoverageDetails
Dental careIn-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $30
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
  • Maximum plan benefit of $2000.00 every year for Non-medicare preventive
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 2 visits (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Fluoride treatment $0
  • Maximum 1 visit every year
Maximum Plan Benefit of $2,000 every year

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
  • Maximum 1 visit every three years
Copayment for Endodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, removable $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Adjunctive general services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision care
Out-of-Network:

Medicare Covered Eye Exams Services:
Coinsurance for Medicare Covered Eye Exams 40%
Coinsurance for Medicare Covered Eyewear 40%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing care
Out-of-Network:

Medicare Covered Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 40%

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.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0

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 1-800-557-6059 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

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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