Healthy Blue Medicare (HMO-POS D-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Blue Cross and Blue Shield of North Carolina.
This page features plan details for 2024 Healthy Blue Medicare (HMO-POS D-SNP) H9147 – 001 – 0 available in Select North Carolina Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Healthy Blue Medicare (HMO-POS D-SNP) is offered in the following locations.
Healthy Blue Medicare (HMO-POS D-SNP) offers the following coverage and cost-sharing.
Special Needs Plan Type: | Dual-Eligible |
Conditions Covered: |
Insurer: | Blue Cross and Blue Shield of North Carolina |
Health Plan Deductible: | |
MOOP: | |
Drugs Covered: | Yes |
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Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$174.70 | $0.00 | $0.00 | $0.00 | $174.70 |
Healthy Blue Medicare (HMO-POS D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $545.00 |
Initial Coverage Limit: | $5,030.00 |
Catastrophic Coverage Limit: | $8,000.00 |
Drug Benefit Type: | Basic |
Additional Gap Coverage: | No |
Formulary Link: | Formulary Link |
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 D | LIS Full |
---|---|
$0.00 | $0.00 |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
After you pay your $545.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
25% | 25% |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
25% | 25% |
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
Generic drugs | ||||
Brand-name drugs |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
Generic drugs | ||||
Brand-name drugs |
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs.
Healthy Blue Medicare (HMO-POS D-SNP) also provides the following benefits.
$0 |
In-network | No |
$8,850 In-network |
No |
In-network | No |
In-network | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
In-network Specialist | $0 copay (Authorization is required.) (Referral is not required.) |
In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
Emergency | $0 copay (Not applicable.) (Not applicable.) |
Urgent care | $0 copay (Not applicable.) (Not applicable.) |
In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Hearing exam | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
In-network Hearing aids | $0 copay (Limits may apply.) (Authorization is 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 | $0 copay (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 | $0 copay (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 | $0 copay (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) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Non-routine services | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
out-of-network Non-routine services | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
In-network Diagnostic services | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic services | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
In-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
out-of-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
In-network Endodontics | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
out-of-network Endodontics | $0 copay (There are no limits.) (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 | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
In-network Extractions | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
out-of-network Extractions | $0 copay (There are no limits.) (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 | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
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.) |
Upgrades | Not covered (Not applicable.) (Not applicable.) |
In-network Occupational therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network | $0 copay (Not applicable.) (Not applicable.) |
In-network | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
In-network Foot exams and treatment | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Routine foot care | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
In-network Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
In-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
In-network Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
Covered (Authorization is not required.) (Referral is not required.) |
In-network Chemotherapy | $0 copay (Authorization is required.) (Not applicable.) |
In-network Other Part B drugs | $0 copay (Authorization is required.) (Not applicable.) |
In-network Part B Insulin drugs | $0 copay (Authorization is required.) (Not applicable.) |
In-network | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network | Not Applicable (Authorization is required.) (Referral is not required.) |
In-network Inpatient hospital – psychiatric | $0 copay (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 | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
In-network | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network | Not Applicable (Authorization is required.) (Referral is not required.) |
Ready to sign up for Healthy Blue Medicare (HMO-POS D-SNP) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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