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Blue Medicare PPO Enhanced (PPO)

H3404 - 003 - 2
4.5 out of 5 stars (4.5 / 5)

Blue Medicare PPO Enhanced (PPO) is a Medicare Advantage Plan by Blue Cross and Blue Shield of North Carolina.

This page features plan details for 2025 Blue Medicare PPO Enhanced (PPO) H3404 – 003 – 2 available in Select North Carolina Counties.

Locations

Blue Medicare PPO Enhanced (PPO) is offered in the following locations.

Alexander County, North Carolina
Anson County, North Carolina
Avery County, North Carolina

Click to see more locations

Plan Overview

Blue Medicare PPO Enhanced (PPO) offers the following coverage and cost-sharing.

Insurer:Blue Cross and Blue Shield of North Carolina
Health Plan Deductible:$0
MOOP:$5,900 In and Out-of-network
$5,900 In-network
Drugs Covered:Yes

Ready to sign up for Blue Medicare PPO Enhanced (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Blue Medicare PPO Enhanced (PPO) has a monthly premium of $45.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $20.10 $24.90 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Blue Medicare PPO Enhanced (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative
Formulary Link: Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$24.90$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Blue Medicare PPO Enhanced (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Endodontics
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Periodontics
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Prosthodontics, removable
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Restorative Services
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – – Copay
    • Out-of-Network: 20% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – – Copay
    • Out-of-Network: 20% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – – Copay
    • Out-of-Network: 20% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – – Copay
    • Out-of-Network: 20% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: 40% coinsurance (Authorization Required)
    • In-Network: $0-25 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0-15 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-300 copay or 20% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0-5 copay (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)

Doctor visits

  • Specialist
    • Out-of-Network: 40% coinsurance per visit
  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $20 copay per visit
    • In-Network: $30 copay per visit
  • Primary
    • Out-of-Network: 40% coinsurance per visit

Emergency care/Urgent care

  • Emergency
    • $120 copay per visit (always covered)
  • Urgent care
    • $55 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $20 copay
    • In-Network: $30 copay
    • Out-of-Network: 40% coinsurance
  • Routine foot care
    • Not covered

Ground ambulance

    • In-Network: $250 copay
    • Out-of-Network: $250 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 40% coinsurance
  • Fitting/evaluation
    • In-Network: $0 copay
    • Out-of-Network: $0 copay
  • Hearing aids
    • In-Network: $699-999 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $30 copay
    • In-Network: $20 copay

Inpatient hospital coverage

    • In-Network: $335 per day for days 1 through 5
      $0 per day for days 6 through 90
      $0 per day for days 91 and beyond (Authorization Required)
    • Out-of-Network: 40% per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $5,900 In and Out-of-network
      $5,900 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 40% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $300 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $20 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $20 copay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $20 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: 40% per stay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $30 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $20 copay (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 40% coinsurance per visit (Authorization Required)
    • In-Network: $335 copay per visit (Authorization Required)

Preventive care

    • Out-of-Network: $0 copay
    • In-Network: $0 copay

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 40% coinsurance
  • Occupational therapy visit
    • In-Network: $10 copay
    • Out-of-Network: 40% coinsurance
  • Physical therapy and speech and language therapy visit
    • In-Network: $10 copay

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 60
      $0 per day for days 61 through 100 (Authorization Required)
    • Out-of-Network: 40% per stay (Authorization Required)

Transportation

    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 40% coinsurance (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Out-of-Network: 40% coinsurance (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $20 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $30 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Blue Medicare PPO Enhanced (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Blue Medicare PPO Enhanced (PPO)? See 2025 Blue Medicare PPO Enhanced (PPO) at MedicareAdvantageRX.com.

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Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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