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Healthy Blue + Medicare (HMO-POS D-SNP)

Blue Cross and Blue Shield of North Carolina
Healthy Blue + Medicare (HMO-POS D-SNP) H9147-001 Plan Details
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Healthy Blue + Medicare (HMO-POS D-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H9147-001

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Healthy Blue + Medicare (HMO-POS D-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H9147-001

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
Blue Cross and Blue Shield of North Carolina
Healthy Blue + Medicare (HMO-POS D-SNP) H9147-001 Plan Details
Not enough data available

Healthy Blue + Medicare (HMO-POS D-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross and Blue Shield of North Carolina
Plan ID: H9147-001

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
$0.00
Monthly Premium

North Carolina Counties Served

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

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$0.00 per day for days 1 to 60
$0.00 per day for days 61 to 90
Deductible $1340.00
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00
Maximum Plan Benefit of $100000.00
Emergency Room Visit
Copayment for Emergency Care $0.00

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0.00
Copayment for Worldwide Emergency Transportation $0.00
Maximum Plan Benefit of $100000.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0.00

Air Ambulance:
Copayment for Air Ambulance Services $0.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Healthy Blue + Medicare (HMO-POS D-SNP) 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 $0.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable Medical Eqipment (DME)
In-Network:
Copayment for Medicare-covered Durable Medical Equipment $0.00
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 $0.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$0.00 per day for days 1 to 60
$0.00 per day for days 61 to 90
Deductible $1364.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00
Prior Authorization Required for Podiatry Services
Prior authorization required
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$0.00 per day for days 21 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
Unlimited allowance. Refer to Evidence of Coverage for details
In-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Non-routine Services $0.00
Copayment for Diagnostic Services $0.00
Copayment for Restorative Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
Copayment for Periodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Prior Authorization Required for Comprehensive Dental

POS (Out-of-Network):

Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00
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 $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $400.00 every year for all Non-Medicare covered eyewear

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 $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00
Maximum Plan Benefit of $3000.00 every year both ears combined
Prior Authorization Required for Hearing Aids
The maximum plan benefit for prescription hearing aid(s) is $3,000 OR a $300.00 maximum plan benefit for over-the-counter hearing aid(s) every year.
Prior authorization required

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

    Prescription Drug Costs and Coverage

    The Healthy Blue + Medicare (HMO-POS D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $0
    Preferred Generic
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Preferred Brand
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Non-Preferred Drug
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Specialty Tier
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Select Care Drugs
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $0
    Preferred Generic
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Preferred Brand
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Non-Preferred Drug
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Specialty Tier
    • Preferred cost-share retail N/A
    • Preferred cost-share mail order N/A
    • Standard retail N/A
    • Standard mail order N/A
    Select Care Drugs
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $0
    Preferred Generic
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Generic
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Preferred Brand
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Non-Preferred Drug
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Specialty Tier
    • Preferred cost-share retail N/A
    • Preferred cost-share mail order N/A
    • Standard retail N/A
    • Standard mail order N/A
    Select Care Drugs
    • Preferred cost-share retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
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