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Blue Medicare PPO Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare PPO Enhanced (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Medicare PPO Enhanced (PPO) in 2025, please refer to our full plan details page.
Blue Medicare PPO Enhanced (PPO) is a PPO plan offered by Blue Cross and Blue Shield of North Carolina available for enrollment in 2025 to people living in Select North Carolina Counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Blue Medicare PPO Enhanced (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Medicare PPO Enhanced (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Blue Medicare PPO Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $25.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $5900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $5900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for Blue Medicare PPO Enhanced (PPO)
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Drug Coverage
The Blue Medicare PPO Enhanced (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays depending on the drug tier and pharmacy type, with some drugs having no copay at preferred mail-order pharmacies. After your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Blue Medicare PPO Enhanced (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services. For inpatient hospital stays, you'll pay a copay for the first few days, with no copay for the rest of the stay. Outpatient services have a copay, and the plan also covers various other services like primary care, preventive services, hearing, vision, and dental, with varying copays or coinsurance. The plan includes coverage for emergency services, ambulance, and transportation, as well as home health and skilled nursing facility care. It also offers additional benefits like over-the-counter items, hearing aids, and a meal benefit. However, the plan has limitations on some services, such as certain hearing aids, and does not cover other services, such as private duty nursing.
Inpatient Hospital See details
Inpatient Hospital coverage includes both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $335 copay for days 1-5, and no copay for days 6-90, with no coinsurance. Additional days for Inpatient Hospital-Acute have no copay or coinsurance. For Inpatient Hospital Psychiatric, you will pay a $300 copay for days 1-5, and no copay for days 6-90, with no coinsurance. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a $335 copay, observation services with a $335 copay, and ambulatory surgical center (ASC) services with a $300 copay. Outpatient substance abuse services include a $20 copay for individual and group sessions. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Medicare PPO Enhanced (PPO) plan. This benefit requires prior authorization and has a $60 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $250 copay for both ground and air ambulance services. Transportation Services to any health-related location are covered with no copay, up to 24 one-way trips per year using rideshare services, bus/subway, or medical transport.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered by the Blue Medicare PPO Enhanced (PPO) plan. Emergency Services has a $120 copay, Urgently Needed Services has a $55 copay, Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $250 copay.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Primary Care Physician Services have no copay, Chiropractic Services have a $20 copay, Occupational Therapy Services have a $10 copay, Physician Specialist Services have a $20 copay, and Physical Therapy and Speech-Language Pathology Services have a $10 copay. Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Additional Telehealth Benefits, and Opioid Treatment Program Services have varying copays, but the minimum copay for each is $10.
Preventive Services See details
Preventive Services, including Medicare-covered preventive services and annual physical exams, are covered with no copay. Additional preventive services and kidney disease education services are covered with no copay. Services such as health education, in-home safety assessments, medical nutrition therapy, and others are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $20 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a copay between $699 and $999, but inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a copay of $0-$20, and eyewear has a 20% coinsurance for contact lenses, but eyeglasses, eyeglass lenses, eyeglass frames, and upgrades have no copay.
Dental Services See details
The Blue Medicare PPO Enhanced (PPO) plan offers dental services with a $20 copay for Medicare dental services and no copay for other dental services. The plan covers oral exams, dental X-rays, cleaning, fluoride treatments, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, and oral and maxillofacial surgery, with varying limitations on the number of visits and specific details. However, maxillofacial prosthetics, implant services, prosthodontics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Blue Medicare PPO Enhanced (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits under the Blue Medicare PPO Enhanced (PPO) plan include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance for Medicare-covered Prosthetic Devices and Medical Supplies. Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay between $0 and $25, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $300 and 20% coinsurance, Therapeutic Radiological Services with a copay up to $60 and 20% coinsurance, and Outpatient X-Ray Services with no copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Blue Medicare PPO Enhanced (PPO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Blue Medicare PPO Enhanced (PPO) plan, but none of the sub-services are covered. The plan does not specify any copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Medicare PPO Enhanced (PPO) plan, but require prior authorization. There is no copay for days 1-20 and days 61-100, but there is a $214 copay for days 21-60.
Other Services See details
Other Services includes coverage for over-the-counter items and a meal benefit. Over-the-counter items have no copay, and the plan offers up to $100 every three months, including nicotine replacement therapy. The meal benefit also has no copay and requires a doctor's referral. Acupuncture, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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