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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 $45.00. 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:
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Drug Coverage
The Blue Medicare PPO Enhanced (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay that varies depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $6 copay at preferred pharmacies and no copay if you use preferred mail order. The plan also offers a Part D premium reduction for those who qualify for the low-income subsidy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for your Part D covered drugs.
Additional Benefits
The Blue Medicare PPO Enhanced (PPO) plan offers a range of benefits, including coverage for inpatient hospital stays with copays, outpatient services with varying copays, and emergency services with copays. You will also find that the plan has coverage for primary care, hearing, vision, and dental services. This plan also includes coverage for ambulance services, home health, and skilled nursing facility (SNF) stays, along with other services. There are some services that are not covered, such as cardiac rehabilitation, and some services require prior authorization.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by the Blue Medicare PPO Enhanced (PPO) plan. For Inpatient Hospital-Acute, you'll pay a $335 copay for days 1-5 and no copay for days 6-90, with additional days 91-999 covered with no copay. Inpatient Hospital Psychiatric has a $300 copay for days 1-5 and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include all outpatient hospital services, observation services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services and observation services have a $335 copay, while ambulatory surgical center services have a $300 copay. Outpatient substance abuse services have a $30 copay for both individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Medicare PPO Enhanced (PPO) plan, but requires prior authorization. You will have a $60 copay for this benefit.
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.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Blue Medicare PPO Enhanced (PPO) plan. Emergency Services have a $120 copay, Urgently Needed Services have a $55 copay, and 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 have no copay, Chiropractic Services have a $20 copay, and Occupational Therapy Services have a $10 copay. Physician Specialist Services have a $30 copay, and Physical Therapy and Speech-Language Pathology Services have a $10 copay. Mental Health and Psychiatric Services have a $30 copay for individual and group sessions, and Other Health Care Professional services have a copay between $0 and $30. Additional Telehealth Benefits have a copay between $0 and $30, and Opioid Treatment Program Services have a $10 copay. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, while other services, such as Health Education, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), and Counseling Services are not covered. The plan also covers additional preventive services with no copay for Personal Emergency Response System (PERS), In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $30 copay, routine hearing exams have no copay, and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are partially covered, with Prescription Hearing Aids (all types) having a copay between $699 and $999, while inner ear, outer ear, and over the ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
The Blue Medicare PPO Enhanced (PPO) plan covers vision services, including eye exams with a copay of $0-$30, and eyewear. Eyewear includes contact lenses with no copay, eyeglasses (lenses and frames) with no copay, eyeglass lenses with no copay, eyeglass frames with no copay, and upgrades with no copay, but contact lenses have a 20% coinsurance.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, and Other Dental Services with no copay. Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Fluoride Treatment, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), and Oral and Maxillofacial Surgery are covered with no copay, while Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while 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 under the Blue Medicare PPO Enhanced (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the Blue Medicare PPO Enhanced (PPO) plan, with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies; Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, with a copay for Medicare-covered diagnostic procedures/tests and lab services that ranges from $0 to $25. Diagnostic Radiological Services have a copay up to $300 and a coinsurance of at least 20%, while Therapeutic Radiological Services have a copay up to $60 and a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Blue Medicare PPO Enhanced (PPO) plan with no copay and no coinsurance, though additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Blue Medicare PPO Enhanced (PPO) plan. Some services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation 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. For days 1-20 and 61-100, there is no copay, and for days 21-60, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items and Meal Benefits. OTC items have no copay and a maximum benefit of $75 every three months, and Meal Benefits have no copay and require a doctor's referral. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, 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, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, 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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