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Blue Medicare Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare Essential (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Medicare Essential (HMO) in 2025, please refer to our full plan details page.
Blue Medicare Essential (HMO) is a HMO 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 (HMO) 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 (HMO).
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 (HMO), 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 $61.00. 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 $590.00 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 $8300.00 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 (HMO) plan has a $590 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions. For preferred generic drugs, you'll pay a $6 copay at a preferred pharmacy or no copay through preferred mail order. Standard generic drugs have a $45 copay at a preferred pharmacy. The plan also covers preferred brand and non-preferred drugs with coinsurance. 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 (HMO) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays. It also covers primary care, specialist visits, and mental health services with copays, and provides no copay for many preventive services. Additional coverage includes ambulance, emergency, and hearing services, with vision and dental services also offered. The plan provides coverage for home health, skilled nursing, and home infusion services, and covers medical equipment and diagnostic services with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $335 copay for days 1-5, and no copay for days 6-90, and for Inpatient Hospital Psychiatric, you'll pay a $300 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay. 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 not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a $335 copay, observation services with a $335 copay, ambulatory surgical center services with a $300 copay, outpatient substance abuse services with a $40 copay for individual or group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Medicare Essential (HMO) plan, with a $40 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Medicare Essential (HMO) plan. Ground and Air Ambulance Services have a $275 copay, with no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Blue Medicare Essential (HMO) plan. Emergency Services have a $100 copay, Urgently Needed Services have a $45 copay, Worldwide Emergency Coverage has a $100 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The Blue Medicare Essential (HMO) plan covers primary care physician services with a $10 copay, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, and specialist services with a $45 copay. Mental health specialty services (individual and group sessions) have a $40 copay, and psychiatric services (individual and group sessions) also have a $40 copay. Physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have a copay between $0 and $45, and opioid treatment program services have a $10 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include no copay for an annual physical exam and zero copay for Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. This plan also covers Personal Emergency Response System (PERS), Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, and Home and Bathroom Safety Devices and Modifications 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, In-Home Support Services, 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
Hearing Services includes hearing exams with a $45 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, while 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
The Blue Medicare Essential (HMO) plan covers vision services, including eye exams with a copay of $0-$25, and eyewear. Eyewear includes contact lenses with no copay, and eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, all with no copay, but a 20% coinsurance applies to contact lenses.
Dental Services See details
Dental Services includes coverage for oral exams, dental x-rays, prophylaxis (cleaning), adjunctive general services, and periodontics with no copay; however, fluoride treatment, restorative services, endodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered. Medicare Dental Services require a $45 copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Blue Medicare Essential (HMO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance, and Diabetic Supplies have between 0% and 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Blue Medicare Essential (HMO) plan. 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 copays of up to $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 (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Blue Medicare Essential (HMO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Medicare Essential (HMO) plan, but require prior authorization. For days 1-20, and days 61-100, there is no copay, but for days 21-60, the copay is $214.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items and Meal Benefits, with no copay for OTC items. 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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