HMO/PPO - Compare Plans

	BLUE MEDICARE HMO			BLUE MEDICARE PPO
	Enhanced plan	Medical-only plan	Standard plan	Enhanced plan	Enhanced Freedom plan
Additional monthly premium^1,4	$80.90	$0	$0	$97.60	$147.50
Provider choice	In-network benefits only Must use a network provider	In-network benefits only Must use a network provider	In-network benefits only Must use a network provider	In- and out-of-network benefits Choose any network physician for less cost Choose an out-of-network physician for higher cost	Choose any network or out-of-network physician at generally the same cost
Primary care physician office visits	$15 copayment for in-network visits only	$5 copayment for in-network visits only	$25 copayment for in-network visits only	$20 copayment for in-network visits Pay 20% coinsurance for out-of-network visits³	$20 copayment for in-network visits Pay $40 copayment for out-of-network visits³
Inpatient hospital benefits	$550 copayment for each Medicare-covered stay	$350 copayment for each Medicare-covered stay	$975 copayment for each Medicare-covered stay	$700 copayment for each Medicare-covered stay	$700 copayment for each Medicare-covered stay
Medicare prescription drug benefit²	Includes our enhanced drug benefit No deductible Generics covered in coverage gap	None	Includes standard drug benefit No deductible No coverage in the coverage gap	Includes our enhanced drug benefit No deductible Generics covered in coverage gap	Includes our enhanced drug benefit No deductible Generics covered in coverage gap
Features	Includes our most robust medical benefits Prescription drug coverage offered	Includes our most robust medical benefits	Basic medical and standard prescription drug coverage	Freedom to visit out-of-network providers	Freedom to visit out-of-network providers at generally the same benefit level as in-network providers
	BLUE MEDICARE HMO			BLUE MEDICARE PPO

Benefits, premium and/or copayment/coinsurance may change on January 1, 2011. Please contact Blue Cross and Blue Shield of North Carolina for more details.

The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a descision about your coverage. This is an advertisement; for more information contact the plan.

Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc. (PARTNERS), a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association.

1 As a member of one of the Blue Medicare HMO or Blue Medicare PPO, you must continue to pay the Medicare B premium in addition to your plan premium.

2 Formulary applies. Refer to the Guide to Medicare Prescription Drug Coverage for details on the Enhanced and Standard packages.

3 Except for emergency or urgent care, you may pay more for out-of-network provider services.

4 If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for the change to take effect, and you will be responsible for premiums during that time.

The information on this page is current as of 10/01/2009.