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Blue Medicare Essential Plus (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare Essential Plus (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Medicare Essential Plus (HMO-POS) in 2025, please refer to our full plan details page.
Blue Medicare Essential Plus (HMO-POS) is a HMO-POS 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 Essential Plus (HMO-POS) 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 Essential Plus (HMO-POS).
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 Essential Plus (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $3.00. You must continue to pay paying your reduced 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 a $375.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 Essential Plus (HMO-POS) plan has a $375 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance based on the drug tier and pharmacy type. For preferred generic drugs, you'll pay a $6 copay at preferred pharmacies and no copay through preferred mail order. For specialty tier drugs, you'll have no copay at preferred pharmacies and preferred mail order, and a $3 copay at standard pharmacies and standard mail order.
Additional Benefits
The Blue Medicare Essential Plus (HMO-POS) plan offers comprehensive coverage with a variety of benefits. You'll find coverage for inpatient and outpatient hospital services, along with primary care, preventive, and emergency services. Additionally, the plan covers hearing, vision, and dental services, and offers no copays for many services, including some preventive care, home health, and over-the-counter items. The plan also includes benefits for ambulance, transportation, and mental health services, with varying copays depending on the service. There are also copays for prescription hearing aids and some vision services. Some services require prior authorization, and some services are not covered, so it is important to review the details of the plan.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For Inpatient Hospital-Acute, you will pay a $400 copay for days 1-5 and no copay for days 6-90, and for Inpatient Hospital Psychiatric, you will pay a $350 copay for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while 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 include coverage for all outpatient hospital services with a $400 copay, observation services with a $400 copay, ambulatory surgical center (ASC) services with a $350 copay, and outpatient substance abuse services with a $20 copay for both individual and group sessions. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Medicare Essential Plus (HMO-POS) plan, but requires prior authorization. The copay for this benefit is $60.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground and air ambulance services with a $300 copay, and transportation services to any health-related location with no copay. Transportation Services - Plan Approved Health-related Location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered under the Blue Medicare Essential Plus (HMO-POS) 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 $300 copay, and there is no coinsurance for any of these services.
Primary Care See details
The Blue Medicare Essential Plus (HMO-POS) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $10 copay, and physician specialist services with a $20 copay. The plan also covers mental health specialty services and psychiatric services, both with a $20 copay for individual and group sessions, and physical therapy and speech-language pathology services with a $10 copay. Additional telehealth benefits are covered with a copay between $0 and $20, and Opioid Treatment Program Services are covered with a $10 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include no copay for Medicare-covered preventive services, annual physical exams, Glaucoma screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, EKG following Welcome Visit, Personal Emergency Response System, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, and Home and Bathroom Safety Devices and Modifications. 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.
Hearing Services See details
The Blue Medicare Essential Plus (HMO-POS) plan covers hearing exams for a $20 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999 per year, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Blue Medicare Essential Plus (HMO-POS) plan covers vision services including eye exams and eyewear. Eye exams have a copay between $0 and $20, and eyewear has a 20% coinsurance for contact lenses.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $20 copay, Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Fluoride Treatment, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), and Oral and Maxillofacial Surgery, all with no copay. Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), and Orthodontics are not covered. The plan has a maximum benefit coverage of $2000 every year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits are covered under the Blue Medicare Essential Plus (HMO-POS) plan. Durable Medical Equipment (DME) has a 20% coinsurance with prior authorization, while durable medical equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have between 0% and 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
The Blue Medicare Essential Plus (HMO-POS) plan covers diagnostic and radiological services, including all diagnostic services, diagnostic procedures/tests with a copay between $0 and $25, and lab services with no copay. The plan also covers diagnostic radiological services with a copay up to $300 and a coinsurance of at least 20%, therapeutic radiological services with a copay up to $60 and a coinsurance of at least 20%, and outpatient X-ray services with no copay.
Home Health Services See details
Home Health Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Blue Medicare Essential Plus (HMO-POS) plan, but the specific services of 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 are not covered. There is a copay for covered services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with 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 for Blue Medicare Essential Plus (HMO-POS) includes coverage for Over-the-Counter (OTC) items with no copay, and meal benefits with no copay, although a doctor's referral is required. 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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