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Blue Medicare Medical Only (HMO-POS)

Blue Cross and Blue Shield of North Carolina
Blue Medicare Medical Only (HMO-POS) H3449-012 Plan Details
4.5 out of 5 stars

Blue Medicare Medical Only (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H3449-012

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Blue Medicare Medical Only (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H3449-012

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Blue Cross and Blue Shield of North Carolina
Blue Medicare Medical Only (HMO-POS) H3449-012 Plan Details
4.5 out of 5 stars

Blue Medicare Medical Only (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H3449-012

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

North Carolina Counties Served

Iredell Alamance Davidson Forsyth Davie Yadkin Chatham Surry Pasquotank Duplin Rowan Wilkes Vance Stokes Anson Randolph Rockingham Northampton Polk Montgomery Moore Caswell Guilford Harnett Orange Lee Durham Person Richmond Johnston Wake Wayne Wilson Franklin Warren Nash Transylvania Graham Gaston Hyde Edgecombe Hertford Chowan Beaufort Martin Halifax Gates Greene Dare Perquimans Camden Stanly Jones Currituck Lincoln Tyrrell Washington Catawba Burke Cleveland Pender Rutherford Mecklenburg Cabarrus Mcdowell Brunswick Pamlico Union Swain Sampson Scotland Hoke New Hanover Cumberland Robeson Columbus Bladen Ashe Yancey Lenoir Caldwell Alexander Jackson Avery Watauga Alleghany Buncombe Henderson Cherokee Mitchell Haywood Clay Madison Macon Granville Bertie Carteret Pitt Onslow Craven

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
Out of Pocket Max In-Network: $3900
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $25
Specialist copay also applies to acupuncture for chronic Low Back Pain (cLBP).
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$295 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $55
Maximum Plan Benefit of $100,000
Emergency Room Visit
Copayment for Emergency Care $120
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 48 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120
Copayment for Worldwide Emergency Transportation $250
Maximum Plan Benefit of $100,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250

Air Ambulance:
Copayment for Air Ambulance Services $250
Prior Authorization Required for Air Ambulance
Prior authorization required

Health Care Services and Medical Supplies

Blue Medicare Medical Only (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $25
Copayment for Medicare-covered Lab Services $0 to $5
Cost sharing will be applied for each service received from each facility each day.Medicare covered diagnostics:Service performed in PCP Office - $0 copayService performed in any other setting - $25 copayDiagnostic colonoscopy: $0 copay

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Copayment for Medicare-covered Therapeutic Radiological Services $0 to $60
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $15
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$295 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $275
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $225
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $100.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $100 every three months
Quitline Program for smoking cessation, the following is available at no cost: 12-wk regimen of combination therapy NRT for up to 2 quit attempts per yearNRT (available for 2 quit attempts, total 24 weeks) Monotherapy (1 type of NRT) Gum = 12 wks = 2 boxes shipment 1, 2 boxes shipment 2, 1 box shipment 3 Lozenge = 12 wks = 4 boxes shipment 1, 1 box shipment 2, 1 box shipment 3 Patch = 1 shipment (4 wk supply of 28 patches)* CNRT=combination NRT Patch + Gum 12 wks = 1 patch + 2 boxes gum shipment 1, 1 patch + 1 box gum shipment 2, 1 patch shipment 3 Patch + Lozenge 12 wks = 1 patch + 2 boxes lozenge shipment 1, 1 patch + 1 box lozenge shipment 2, 1 patch shipment 3
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $25
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 60
$0 per day for days 61 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $25
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
  • Maximum plan benefit of $2000.00 every year for Non-medicare preventive
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 2 visits (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Fluoride treatment $0
  • Maximum 1 visit every year
Maximum Plan Benefit of $2,000 every year

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, removable $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Adjunctive general services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $25
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $300 every year

Eyewear:
Coinsurance for Medicare-Covered Benefits 20%
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
Copayment for Eyeglass Lenses $0
Copayment for Eyeglass Frames $0
Copayment for Upgrades $0

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $25
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0

Hearing Aids:
Copayment for Hearing Aids $699 to $999
  • Maximum 2 Hearing Aids every year
$699 for Advanced hearing aids. $999 for Premium hearing aids. Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearing s Advanced and Premium hearing aids, which come in various styles and colors and are available in rechargeable style options for an additional $50 per aid. You must see a TruHearing provider to use this benefit. *Routine hearing exam cost and hearing aid copayments are not subject to the out-of-pocket maximum.Hearing aid purchase includes: First year of follow-up provider visits 60-day trial period 3-year extended warranty 80 batteries per aid for non-rechargeable modelsBenefit does not include or cover any of the following: Additional cost for optional hearing aid rechargeability Ear molds Hearing aid accessories Additional provider visits Additional batteries, batteries when a rechargeable hearing aid is purchased Hearing aids that are

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit
    Back to Plans in North Carolina