A non-government entity
Experience Health Medicare Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Experience Health Medicare Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Experience Health Medicare Advantage (HMO) in 2025, please refer to our full plan details page.
Experience Health Medicare Advantage (HMO) is a HMO plan offered by Blue Cross and Blue Shield of North Carolina available for enrollment in 2025 to people living in Triangle and surrounding area. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Experience Health Medicare Advantage (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 Experience Health Medicare Advantage (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 Experience Health Medicare Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $25.00. 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 Maximum Out-Of-Pocket cost of $3900.00 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 Experience Health Medicare Advantage (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay for your prescriptions. For example, standard generic drugs have a $5 copay. This plan's premium may be reduced if you qualify for the low-income subsidy (LIS). Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Experience Health Medicare Advantage (HMO) plan offers comprehensive coverage with a variety of benefits. This plan includes coverage for inpatient hospital stays, outpatient services, emergency services, primary care, preventive services, hearing, vision, dental, and more. Many services have no copay, and some services have a copay or coinsurance, such as inpatient hospital stays, ambulance, and dental services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $295 per day for days 1-6, and no copay for days 7-90 for Inpatient Hospital-Acute. Additional days for Inpatient Hospital-Acute have no copay for days 91-999, but the plan does not cover Non-Medicare-covered stays or upgrades for Inpatient Hospital-Acute. Inpatient Hospital Psychiatric has a copay of $275 per day for days 1-6, and no copay for days 7-90. 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 $200 copay, Observation Services with no copay, Ambulatory Surgical Center (ASC) Services with a $200 copay, Individual and Group Sessions for Outpatient Substance Abuse with no copay, and Outpatient Blood Services with 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the Experience Health Medicare Advantage (HMO) plan, with prior authorization required. There is no copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground and air ambulance services, each with a $295 copay, and transportation services to a plan-approved health-related location with no copay. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered. Emergency Services have a $120 copay, Urgently Needed Services have a $60 copay, Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $60 copay, and Worldwide Emergency Transportation has a $295 copay. There is no coinsurance for any of these services.
Primary Care See details
Primary Care benefits include coverage for primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $20 copay. Physician specialist services, physical therapy, and speech-language pathology services each have a $20 copay. Mental health and psychiatric services have no copay for individual and group sessions, and other health care professionals have a copay between $0 and $20. Additional telehealth benefits have a copay between $0 and $20, and opioid treatment program services have no copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, an annual physical exam with no copay, additional preventive services, and Kidney Disease Education Services with no copay. Additional preventive services include Fitness Benefit, Personal Emergency Response System, In-Home Support Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. 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, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, and Counseling Services are not covered.
Hearing Services See details
The Experience Health Medicare Advantage (HMO) plan covers hearing exams with no copay, routine hearing exams once per year with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $599 and $899, while OTC hearing aids, and prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Experience Health Medicare Advantage (HMO) plan covers vision services, including eye exams and eyewear. Eye exams, routine eye exams, other eye exam services, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades have no copay.
Dental Services See details
The Experience Health Medicare Advantage (HMO) plan covers dental services with a $20 copay for Medicare Dental Services and no copay for other dental services. Orthodontic services have a $1,500 maximum benefit per year, while other dental services like Oral Exams, Dental X-Rays, and more have no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but 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 by the Experience Health Medicare Advantage (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
The Experience Health Medicare Advantage (HMO) plan covers durable medical equipment with 20% coinsurance and requires prior authorization. Prosthetic devices and medical supplies have a 20% coinsurance, and diabetic equipment is covered with coinsurance for Medicare-covered diabetic supplies and a copay for therapeutic shoes or inserts. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a copay for some services. Diagnostic Procedures/Tests have a copay between $0 and $20, Lab Services have no copay, and Diagnostic Radiological Services have a copay up to $150. Therapeutic Radiological Services have no copay and up to 20% coinsurance, while Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Experience Health Medicare Advantage (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 covered under the Experience Health Medicare Advantage (HMO) plan. However, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20 and 61-100, there is no copay, but for days 21-60, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture has a $50 copay per visit, and is limited to 20 treatments per year. OTC items are covered up to $116 every three months, and the meal benefit has no copay and requires a doctor's referral. The plan does not cover 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, or Self-Directed Personal Assistance Services.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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