BlueCross BlueShield of North Carolina

Blue Medicare PPOSM

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Blue Medicare PPO, one of our Medicare Advantage plans, provides coverage for:

  • Inpatient/outpatient services
  • Skilled nursing facility care
  • Home health care
  • Worldwide emergency medical care
  • Ambulance and urgent care
  • Preventive care

Blue Medicare PPO (Preferred Provider Organization) is a Medicare Advantage plan where your care and services from doctors and hospitals are in the plan's network, but also allows you to see doctors outside the network, usually at a higher cost. It provides your Medicare Parts A and B coverage, while keeping your out-of-pocket costs lower.

It also includes:

  • Health care benefits and Medicare prescription drug coverage, combined in one plan1
  • No referral needed to see a specialist
  • Predictable copayments and costs
  • Fill your prescriptions at participating pharmacies throughout the state, including most of the major chain pharmacies, or through our mail order prescription program
  • Additional savings with our Preferred Pharmacy network, which includes CVS, Walmart, Kerr and Epic pharmacies
  • Healthways SilverSneakers®1 Fitness Program at no additional cost2
  • Additional savings with our Blue365® discount program3

There are two Blue Medicare PPO plans: Enhanced and Enhanced Freedom. While each cover the same benefits, there are differences in the amounts you pay for out-of-network services, copayments and inpatient hospital stays. Look at a side-by-side comparison of our Blue Medicare HMO plans.

Is Blue Medicare PPO Available in Your Area?

Our service area map can show you if Blue Medicare PPO is available in your county.

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  1. A formulary applies for all plans that include Medicare prescription drug coverage.
  2. The SilverSneakers program is provided by Healthways, Inc., a third-party vendor independent of BCBSNC. The program is available only to members covered under Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Supplement plans. BCBSNC is not liable in any way for the services received; results are not guaranteed. Decisions regarding medical care should be made with the advice of a doctor. SilverSneakers is a registered trademark of Healthways, Inc.
  3. Blue365 offers access to savings on items that Members may purchase directly from independent vendors, which are different from items that are covered under the policies with BCBSNC. Any disputes regarding these products and services may be subject to BCBSNC's grievance process. The Blue Cross and Blue Shield Association (BCBSA) may receive payments from Blue365 vendors. Neither BCBSNC nor BCBSA recommends, endorses, warrants or guarantees any specific Blue365 vendor or item. This program may be modified or discontinued at any time without prior notice.

®, SM Marks of the Blue Cross and Blue Shield Association. ®1 Mark of Healthways, Inc.

Important Legal Information and Disclaimers

U9405, 10/13

The information on this page is current as of 10/01/2013.

Y0079_6246 CMS Approved 10212013

How do the different Blue Medicare PPO plans work? What about Part D prescription drug benefits?

The following charts can help answer those questions by comparing:

  • Blue Medicare PPO (Enhanced and Enhanced Freedom)1
  • Part D Benefits for Blue Medicare PPO

Compare Plans

Enhanced Plan Enhanced Freedom Plan
Monthly Member Premium2,3 $38 $121.30
Features
  • Freedom to visit out-of-network providers
  • Freedom to visit out-of-network providers at generally the same benefit level as in-network providers
Provider choice
  • In- and out-of-network benefits
  • Choice of any network physician for less cost
  • Choice of an out-of-network physician for higher cost
  • Choice of any network or out-of-network physician at generally the same cost
Primary care physician office visits
  • $20 copayment for in-network visits
  • Pay 20% coinsurance for out-of-network visits
  • $15 copayment for in-network visits
  • Pay $35 for out-of-network visits
Inpatient hospital stay per day
  • $220, Up to 7 days
  • $170, Up to 7 days
Medicare prescription drug benefit
  • Includes our standard drug benefit
  • No deductible
  • You pay the following up to $2850 out-of-pocket
  • Includes our enhanced drug benefit
  • No deductible
  • You pay the following up to $2850 out-of-pocket
During the coverage gap
  • 72% on all generics
  • a discount on brand name drugs until your yearly out-of-pocket drug costs reach $4,550
  • $3 for preferred pharm
  • $8 for non-preferred pharm
  • 72% on all other generics
  • a discount on brand name drugs until your yearly out-of-pocket drug costs reach $4,550
Catastrophic Coverage
  • You pay 5%
  • After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 for brand name or 5% of the total drug cost.
  • You pay 5%
  • After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 for brand name or 5% of the total drug cost.
Montly Member Premium 2,3
Enhanced Plan $38
Enhanced Freedom Plan $121.30
Features
Enhanced Plan
  • Freedom to visit out-of-network providers
Enhanced Freedom Plan
  • Freedom to visit out-of-network providers at generally the same benefit level as in-network providers
Provider Choice
Enhanced Plan
  • In- and out-of-network benefits
  • Choice of any network physician for less cost
  • Choice of an out-of-network physician for higher cost
Enhanced Freedom Plan
  • Choice of any network or out-of-network physician at generally the same cost
Primary care physician office visits4
Enhanced Plan
  • $20 copayment for in-network visits
  • Pay 20% coinsurance for out-of-network visits
Enhanced Freedom Plan
  • $15 copayment for in-network visits
  • Pay $35 for out-of-network visits
Inpatient hospital stay per day
Enhanced Plan
  • $220, Up to 7 days
Enhanced Freedom Plan
  • $170, Up to 7 days
Medicare prescription drug benefit
Enhanced Plan
  • Includes our standard drug benefit
  • No deductible
  • You pay the following up to $2850 out-of-pocket
Enhanced Freedom Plan
  • Includes our standard drug benefit
  • No deductible
  • You pay the following up to $2850 out-of-pocket
During the coverage gap
Enhanced Plan
  • 72% on all generics
  • a discount on brand name drugs until your yearly out-of-pocket drug costs reach $4,550
Enhanced Freedom Plan
  • $3 for preferred pharm
  • $8 for non-preferred pharm
  • 72% on all other generics
  • a discount on brand name drugs until your yearly out-of-pocket drug costs reach $4,550
Catastrophic Coverage
Enhanced Plan
  • You pay 5%
  • After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 for brand name or 5% of the total drug cost.
Enhanced Freedom Plan
  • You pay 5%
  • After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 for brand name or 5% of the total drug cost.

View a side-by-side comparison of Blue Medicare HMO and Blue Medicare PPO

Compare Part D Benefits

Medicare offers prescription drug (Part D) coverage, as part of most Medicare Advantage plans, to help you pay for your prescription drugs.3 With this coverage, you can fill your prescriptions at participating pharmacies close to where you live, or through our convenient mail-order pharmacy services.4 You'll have greater savings using our Preferred Pharmacy network, which includes CVS, Walmart, Kerr and Epic pharmacies.

Part D coverage is available with Blue Medicare PPO plans. That means you have your medical benefits and prescription drug coverage in one plan, for one premium.

How much will your prescription drugs cost you? Here's what you could expect to pay for a 30-day prescription supply, depending on where you to to purchase your prescription drugs:

Preferred Retail Pharmacy
(CVS, Walmart, Kerr & Epic)
Non-Preferred Retail Pharmacy Preferred Mail Order Service
Drug List Tiers PPO Enhanced PPO Enhanced Freedom PPO Enhanced PPO Enhanced Freedom PPO Enhanced PPO Enhanced Freedom
Tier 1 - Preferred Generic Drugs $3 $3 $8 $8 $3 $3
Tier 2 - Non-Preferred Generic Drugs $6 $6 $25 $20 $6 $6
Tier 3 - Preferred Brand-Name Drugs $40 $30 $45 $45 $40 $30
Tier 4 - Non-Preferred Brand-Name Drugs $80 $70 $95 $95 $80 $70
Tier 5 - Specialty Drugs 33% 33% 33% 33% 33% 33%

You pay the copayment per 30-day supply or coinsurance until your drugs, and the plan pays the remainder until the total drug costs reach $2850.

After your total yearly drug costs reach $2850, you have reached the Coverage Gap: you receive limited coverage on certain drugs and pay the following:

Preferred Retail Pharmacy
(CVS, Walmart, Kerr & Epic)
Non-Preferred Retail Pharmacy Preferred Mail Order Service
PPO Enhanced PPO Enhanced Freedom PPO Enhanced PPO Enhanced Freedom PPO Enhanced PPO Enhanced Freedom
Generally pay up to 72% for generic drugs and generally no more than 47.5% for brand drugs For Tier 1, preferred generics, you pay $3. For all other generics, you generally pay up to 72% and generally no more than 47.5% for brand drugs. Generally pay up to 72% for generic drugs and generally no more than 47.5% for brand drugs For Tier 1, preferred generics, you pay $3. For all other generics, you generally pay up to 72% and generally no more than 47.5% for brand drugs. Generally pay up to 72% for generic drugs and generally no more than 47.5% for brand drugs For Tier 1, preferred generics, you pay $3. For all other generics, you generally pay up to 72% and generally no more than 47.5% for brand drugs.

After you reach $4550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 for brand-name or 5% of the total drug costs.

How much will your prescription drugs cost you? Here's what you could expect to pay for a 30-day prescription supply, depending on where you to to purchase your prescription drugs:

Preferred Retail Pharmacy
(CVS, Walmart, Kerr & Epic)
PPO Enhanced PPO Enhanced Freedom
Tier 1 - Preferred Generic Drugs $3 $3
Tier 2 - Non-Preferred Generic Drugs $6 $6
Tier 3 - Preferred Brand-Name Drugs $40 $30
Tier 4 - Non-Preferred Brand-Name Drugs $80 $70
Tier 5 - Specialty Drugs 33% 33%
Non-Preferred Retail Pharmacy
PPO Enhanced PPO Enhanced Freedom
Tier 1 - Preferred Generic Drugs $8 $8
Tier 2 - Non-Preferred Generic Drugs $25 $20
Tier 3 - Preferred Brand-Name Drugs $45 $45
Tier 4 - Non-Preferred Brand-Name Drugs $95 $95
Tier 5 - Specialty Drugs 33% 33%
Preferred Mail Order Service
PPO Enhanced PPO Enhanced Freedom
Tier 1 - Preferred Generic Drugs $3 $3
Tier 2 - Non-Preferred Generic Drugs $6 $6
Tier 3 - Preferred Brand-Name Drugs $40 $30
Tier 4 - Non-Preferred Brand-Name Drugs $80 $70
Tier 5 - Specialty Drugs 33% 33%

You pay the copayment per 30-day supply or coinsurance until your drugs, and the plan pays the remainder until the total drug costs reach $2850.

After your total yearly drug costs reach $2850, you have reached the Coverage Gap: you receive limited coverage on certain drugs and pay the following:

Preferred Retail Pharmacy
(CVS, Walmart, Kerr & Epic)
PPO Enhanced Generally pay up to 72% for generic drugs and generally no more than 47.5% for brand drugs
PPO Enhanced Freedom For Tier 1, preferred generics, you pay $3. For all other generics, you generally pay up to 72% and generally no more than 47.5% for brand drugs.
Non-Preferred Retail Pharmacy
PPO Enhanced Generally pay up to 72% for generic drugs and generally no more than 47.5% for brand drugs
PPO Enhanced Freedom For Tier 1, preferred generics, you pay $3. For all other generics, you generally pay up to 72% and generally no more than 47.5% for brand drugs.
Preferred Mail Order Service
PPO Enhanced Generally pay up to 72% for generic drugs and generally no more than 47.5% for brand drugs
PPO Enhanced Freedom For Tier 1, preferred generics, you pay $3. For all other generics, you generally pay up to 72% and generally no more than 47.5% for brand drugs.

After you reach $4550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 fir brand-name or 5% of the total drug costs.

Drug List (Formulary) for Blue Medicare PPO

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  1. With the exception of emergency or urgent care, member liability with Blue Medicare PPO may be greater for services received out-of-network than services received in-network. Many out-of-network services are subject to coinsurance, which are based on the Medicare allowed amount and not on the potentially lower contract amount.
  2. You must continue to pay the Medicare Part B premium in addition to your plan premium.
  3. Formulary applies for all plans that include Medicare prescription drug coverage.
  4. Beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

Important Legal Information and Disclaimers

U9405a, 10/13

The information on this page is current as of 10/01/2013.

Y0079_6246 CMS Approved 10212013

To be eligible for Blue Medicare PPO, you must:

  • Be entitled to Medicare Part A and enrolled in Medicare Part B
  • Live in the plan's service area. Make sure Blue Medicare PPO is available in your county.

Federal law states you may be ineligible to join Blue Medicare PPO if you have end-stage renal disease (ESRD), unless you qualify. Contact us for more information.

Enrollment Periods

Annual enrollment period (AEP): October 15 through December 7 of every year.
Annual disenrollment period: January 1 through February 14 of every year.

The initial coverage enrollment period begins three months immediately before you become eligible for both Medicare Part A and Part B and ends on the later of either:

  • The last day of the month preceding your eligibility to both Part A and Part B, or
  • The last day of your Part B initial enrollment period.

Special Enrollment Periods

There are some limited situations where you could change outside of the AEP, October 15 – December 7 period. For example, if you moved out of your plan's service area, you'd have the chance to pick another plan based on your new location. Contact us for more information about this and other situations that qualify.

Delayed Enrollment

If you didn't enroll in Medicare Parts A, B or D coverage when you were first eligible, you may enroll during the AEP each year thereafter. You may also be eligible to enroll during a special enrollment period, depending on your situation. For Part D, you may have to pay a late enrollment penalty premium.

Give us a call at 1-800-665-8037, 7 days a week, 8 a.m. - 8 p.m. to learn more. TTY/TDD users, call 1-800-922-3140.

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While everyone with Medicare is eligible for Part D coverage, you're not required to have Part D. But, if you don't enroll in Part D when you first become eligible, you may have to pay more for prescription drug coverage if you decide to enroll later.

Important Legal Information and Disclaimers

U9405b, 10/13

The information on this page is current as of 10/01/2013.

Y0079_6246 CMS Approved 10212013

You have two choices when it comes to enrolling in a Blue Medicare PPO plan: online application or paper application. But before you pick how you enroll, you should first:

  • Choose a plan. After you've reviewed our plans, pick the one that best meets your needs. If you need help picking the right plan, we can help you choose.
  • Choose a doctor. If you don't already have a doctor, or a primary care physician (PCP), you can search for doctors available in the plan you select. If you need help, contact us.

The enrollment form will ask for your primary care phycian's PCP code (also known as NPI #). Please write it down to enter on your enrollment form.

Once you've picked a plan and a doctor, you can start enrolling in a Blue Medicare PPO plan.

Enroll Online

Enter and submit your enrollment form safely, quickly and easily:

Enroll Now Remind Me

Enroll by Paper

Blue Medicare PPO Enrollment
P.O. Box 17168
Winston-Salem, NC 27116

If you'd rather request the enrollment form over the phone, or if you have enrollment questions, call us at 1-800-665-8037, seven days a week, 8 a.m. - 8 p.m. TTY/TDD users, call 1-800-922-3140.

We'll mail you an enrollment kit that includes the enrollment form, a Summary of Benefits document and additional plan information.

Additional Links for Blue Medicare PPO

Medical and Drug Plan Ratings for Blue Medicare PPO (pdf)

Multi-Language Intepreter Services (pdf)

Blue Medicare PPO Product Brochure (pdf)

Other Enrollment Options

You can also enroll in Blue Medicare PPO Enhanced or Blue Medicare PPO Enhanced Freedom through the CMS Medicare Online Enrollment Center.

Important Legal Information and Disclaimers

U9405c, 10/13

The information on this page is current as of 10/01/2013.

Y0079_6246 CMS Approved 10212013

You can enroll in Medicare Advantage plans only during specific times of the year. Enrollment dates are available at Medicare.gov or by calling 1-800-665-8037, 8 a.m. - 8 p.m., seven days a week (TDD/TYY: 1-800-922-3140).

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