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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 $5200.00 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 type. For example, for preferred generic drugs at a preferred mail order pharmacy, there is no copay. The plan offers different copays and coinsurance amounts for various drug tiers and pharmacy types, including preferred and standard pharmacies, as well as mail-order options. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Blue Medicare Essential Plus (HMO-POS) plan offers a wide range of benefits with varying costs. Inpatient hospital stays have a copay, and outpatient services have copays for services such as hospital, observation, substance abuse, and ambulatory surgical center services. The plan also includes coverage for ambulance, emergency, and primary care services, often with copays ranging from $0 to $300. The plan provides comprehensive preventive services with no copay for many services, as well as coverage for hearing, vision, and dental services, though some services like certain hearing aids, orthodontics, and maxillofacial prosthetics are not covered. Additional benefits include coverage for home infusion, dialysis, medical equipment, diagnostic and radiological services, home health, cardiac rehabilitation, skilled nursing facility, and other services like OTC items, often with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $400 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute, and a copay of $350 for days 1-5 and no copay for days 6-90 for Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services for the Blue Medicare Essential Plus (HMO-POS) plan includes coverage for 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 $30 copay for both individual and group sessions. Outpatient Blood Services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Medicare Essential Plus (HMO-POS) plan, but requires prior authorization. The plan has a $60 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan. Ground and air ambulance services have a $300 copay, and transportation services to any health-related location have no copay. Transportation services to plan-approved health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Blue Medicare Essential Plus (HMO-POS) plan. Emergency Services have a $120 copay, while Urgently Needed Services have a $55 copay, and Worldwide Emergency Services have varying copays depending on the service. Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $300 copay.
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. The plan also covers Occupational Therapy Services with a $10 copay, Physician Specialist Services with a $30 copay, and Physical Therapy and Speech-Language Pathology Services with a $10 copay. Mental Health and Psychiatric Services, Other Health Care Professional, and Opioid Treatment Program Services have varying copays depending on the specific service. Additional Telehealth Benefits are covered with a copay ranging from $0 to $30. However, Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Blue Medicare Essential Plus (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. The plan also covers additional preventive services such as Personal Emergency Response System (PERS), In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Home and Bathroom Safety Devices and Modifications, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay. 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 with a $30 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, but prescription hearing aids for 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 with a copay of $0-$30, and eyewear. Eyewear services have a 20% coinsurance, with contact lenses and no copay for eyeglasses, eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Blue Medicare Essential Plus (HMO-POS) plan covers dental services with a $2,000 annual maximum benefit. Medicare dental services require a $30 copay, while oral exams, dental X-rays, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery have no copay. 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 are covered with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
The Blue Medicare Essential Plus (HMO-POS) plan covers medical equipment, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices and Medical Supplies with 20% coinsurance. The plan also covers Diabetic Equipment, with Diabetic Supplies having a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts having a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan. Diagnostic Procedures/Tests have a copay between $0 and $25, while Lab Services have no copay. Diagnostic Radiological Services and Therapeutic Radiological Services have a coinsurance of at most 20% and copays 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. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Blue Medicare Essential Plus (HMO-POS) plan. However, 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, or Additional Cardiac Rehabilitation Services.
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
The Blue Medicare Essential Plus (HMO-POS) plan covers Over-the-Counter (OTC) Items with no copay. This plan also covers a meal benefit with no copay, and requires a doctor's referral. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and many other services are not covered.
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