Blue Medicare Medical Only (HMO-POS)
H3449 - 012 - 0
(4 / 5)
Blue Medicare Medical Only (HMO-POS) is a Medicare Advantage (Part C) Plan by Blue Cross and Blue Shield of North Carolina.
This page features plan details for 2024 Blue Medicare Medical Only (HMO-POS) H3449 – 012 – 0 available in Select North Carolina Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Blue Medicare Medical Only (HMO-POS) is offered in the following locations.
Plan Overview
Blue Medicare Medical Only (HMO-POS) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross and Blue Shield of North Carolina |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,900 In-network |
| Drugs Covered: | No |
Ready to sign up for Blue Medicare Medical Only (HMO-POS) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Blue Medicare Medical Only (HMO-POS) qualifies for a monthly Medicare Give Back Benefit of $50.00.
| Premium Reduction: | $50.00 |
Premium Breakdown
Blue Medicare Medical Only (HMO-POS) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $50.00 | $124.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Blue Medicare Medical Only (HMO-POS) also provides the following benefits.
| $0 |
| In-network | No |
| $3,900 In-network |
| No |
| In-network | No |
| In-network | $275 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $60 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Lab services | $0-5 copay (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-300 copay or 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0-15 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $25 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Other | $25 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Occupational therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $250 copay (Not applicable.) (Not applicable.) |
| In-network | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| In-network | $295 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 90 and beyond (Authorization is required.) (Referral is not required.) |
| out-of-network | Not Applicable (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $295 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | Not Applicable (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 60 $0 per day for days 61 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | Not Applicable (Authorization is required.) (Referral is not required.) |
Ready to sign up for Blue Medicare Medical Only (HMO-POS) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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