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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 the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you'll pay a $6 copay at preferred pharmacies and no copay for preferred mail order. For specialty tier drugs, you'll pay no copay at preferred pharmacies or mail order. You will pay coinsurance for preferred brand and non-preferred drugs.
Additional Benefits
The Blue Medicare Essential Plus (HMO-POS) plan offers a wide range of benefits with varying costs. Inpatient hospital stays require a copay, while outpatient services have copays for specific services like hospital and ASC services. Emergency, primary care, and preventive services are covered, with many services having no copay. This plan includes coverage for hearing, vision, and dental services, with copays for some services and coinsurance for others. It also provides benefits for home health, medical equipment, and diagnostic services, with copays and coinsurance depending on the service. Additionally, the plan offers an over-the-counter item benefit, as well as a meal benefit.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization required. 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 Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by the Blue Medicare Essential Plus (HMO-POS) plan, including outpatient hospital services with a $400 copay, observation services with a $400 copay, ambulatory surgical center (ASC) services with a $350 copay, individual and group outpatient substance abuse sessions with a $20 copay, and outpatient blood services with no copay. Prior authorization is required for outpatient hospital and ASC services.
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 are covered, with no coinsurance. Ground and air ambulance services have a $300 copay, while transportation services to any health-related location have no copay, and plan-approved health-related location transportation services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan. Emergency Services have a $120 copay with no coinsurance, and the copay is waived if admitted to the hospital within 48 hours. Urgently Needed Services have a $55 copay with no coinsurance. Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $300 copay, all with no coinsurance; these services have a maximum benefit of $100,000.
Primary Care See details
The Blue Medicare Essential Plus (HMO-POS) plan covers primary care physician services with no copay, and chiropractic services with a $20 copay. Occupational therapy services have a $10 copay, while physician specialist services and physical therapy/speech-language pathology services each have a $20 and $10 copay, respectively. Mental health and psychiatric services have a minimum copay of $20 for individual and group sessions, and other health care professional services have a copay between $0 and $20. Additional telehealth benefits have a copay between $0 and $20, and opioid treatment program services have a $10 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional preventive services, including health education, in-home safety assessment, medical nutrition therapy, 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, and counseling services which are not covered. The plan also covers kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, all with no copay.
Hearing Services See details
The Blue Medicare Essential Plus (HMO-POS) plan covers hearing exams with a $20 copay, routine hearing exams once per year 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, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay between $0 and $20, and routine eye exams have no copay, while other eye exam services have a $20 copay. Eyewear has 20% coinsurance for contact lenses, and eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades have no copay.
Dental Services See details
The Blue Medicare Essential Plus (HMO-POS) plan covers Medicare Dental Services with a $20 copay, and other dental services, with a $2,000 annual maximum. 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, including Medicare Part B Insulin Drugs with a $35 copay. 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 Essential Plus (HMO-POS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered, including durable medical equipment (DME) with 20% coinsurance and requiring authorization, prosthetics/medical supplies with 20% coinsurance, and diabetic equipment, with 0-20% coinsurance depending on the specific service. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, are covered with prior authorization. Diagnostic Procedures/Tests have a copay between $0 and $25, and Lab Services have no copay. Diagnostic Radiological Services and Therapeutic Radiological Services have a coinsurance of at most 20% and a copay of at most $300 and $60, respectively. Outpatient X-Ray Services have 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. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan, but the specific services are not covered. There is a copay for some services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization required. There is no copay for days 1-20 and days 61-100, but a $214 copay for days 21-60; there is no coinsurance. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Blue Medicare Essential Plus (HMO-POS) plan's "Other Services" benefit covers over-the-counter items with no copay, and a maximum benefit of $82 every three months. Acupuncture, Dual Eligible SNPs, 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. The plan also offers a meal benefit with no copay, and a doctor referral is required.
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