Original Medicare is your Part A hospital benefits and Part B medical benefits. It is administered by the federal government.
Medicare Part C is provided by private insurance companies, like Blue Cross NC. It covers the same types of care as Medicare Parts A and B but lowers your share of the costs when you use doctors and hospitals that are part of the plan’s network.
In addition, most Medicare Advantage plans offer prescription drug coverage and supplemental benefits such as gym memberships, vision coverage, dental coverage, and more.
Medicare Supplement Insurance, sometimes called Medigap, are policies offered by private insurers and are standardized by the federal government. These plans help fill gaps in Original Medicare and may cover some or all of the costs not covered by Original Medicare such as copayments, coinsurance, and deductibles.
Medicare Part D is prescription drug coverage for those enrolled in Original Medicare (Parts A and/or B). Plans are available from private insurers, like Blue Cross NC.
If you are enrolled in a Medicare Advantage plan, you are not eligible for this standalone prescription drug coverage. If you are interested in a Medicare Advantage plan and need drug coverage, be sure to choose a Medicare Advantage plan that includes drug coverage.
Original Medicare covers many preventive services, such as flu shots and pneumonia shots.
Both Original Medicare and Medicare Advantage cover pre-existing conditions. Medicare Supplement plans may be subject to a waiting period.
Yes. Medicare covers one flu shot per year. If you are seeing your doctor for more than a flu shot, you may still be charged a copay for that visit if applicable to your plan.
Yes. Medicare Part B covers two different pneumococcal shots. The first shot can be administered at any time; the second must be given at least one year after the first shot in order to be covered.
No. Medicare Part B does not cover the shingles vaccine; however, Medicare Part D does.
Medicare Advantage plans may include dental, hearing and vision benefits and/or allowances. Original Medicare and some Medicare Supplement plans do not cover dental, hearing and vision services that are not medically necessary, but you can purchase dental or vision plans separately.
Expenses for long-term care facilities, such as nursing homes, are not covered. However, Medicare does include benefits for a skilled nursing facility for rehabilitation and medical treatment (from a surgery or other significant inpatient medical procedure).
With Original Medicare and Medicare Supplement, you can see any doctor or visit any hospital that accepts Medicare. Some plans also offer coverage for foreign travel and foreign emergency care. With Medicare Advantage PPO plans, you may use your out-of-network benefits when traveling outside the service area. Medicare Advantage HMO plans provide coverage in the event of an emergency.
Some medications may be covered under Original Medicare’s Part B benefits. For more robust coverage, you may purchase a Medicare Rx (Part D) plan to add to Original Medicare, or purchase a Medicare Advantage plan that includes prescription coverage.
Original Medicare and Medicare Supplement provide coverage at any Medicare-participating doctor or hospital coast-to-coast. Medicare Advantage plans are coordinated care plans, which means they are built around a network of doctors and hospitals working together to provide your care.
To maintain your Medicare coverage, you must stay current on your monthly premiums.
You can begin your Medicare enrollment at https://www.ssa.gov/benefits/medicare/. If you’d like to purchase a Medicare Advantage plan, Medicare Supplement plan or Medicare Prescription Drug plan (PDP), you need to enroll in Parts A and/or B before purchasing those plans.
Some people get Medicare Part A and Medicare Part B automatically, and other people have to sign up. In most cases, it depends on whether you’re getting Social Security benefits. You can learn more at Medicare.gov.
Medicare Part A is usually available at no cost if you or your spouse made payroll contributions to Social Security for at least 10 years. Medicare Part B comes with a monthly premium based on your income. Some Medicare Advantage (Part C) plans, Medicare Supplement and Medicare Rx (Part D) also come with a monthly premium.
You still qualify for Medicare at age 65, but it may or may not make sense to enroll. Check with your employer’s human resources manager, benefits specialist, or a Blue Cross NC agent to learn about your options.
In some cases, if you keep your current coverage and wait until later to join Medicare, you may have fewer choices and/or pay more.
You can discontinue your Medicare coverage to enroll under an employer plan. When you’re ready for Medicare again, you’ll still be eligible under a Special Enrollment Period.
Check with your human resources manager or benefits specialist to see your options. In some cases, if you keep your current coverage and wait until later to join Medicare, you may have fewer choices and/or pay more.
If you enroll in Parts A, B or D after 3 months from your eligibility date, you may have to pay a higher premium for Parts B and D. This penalty is required by the federal government. For more information about late enrollment, visit Medicare.gov.
Yes. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.
If you have Medicare and Medicaid, you already qualify for low income assistance. If you don’t qualify for Medicaid, you may still qualify for some assistance. The amount of assistance will depend on your income and resources and will be applied to the cost of the Medicare prescription drug coverage portion of your Blue Medicare HMO or PPO plan.
Learn more about financial assistance: https://medicare.bluecrossnc.com/medicare/help-premiums
There are two opportunities for everyone to switch plans: the Annual Enrollment Period (AEP) October 15 to December 7 and the Open Enrollment Period (OEP) January 1 to March 31.
For example, if you enroll or switch plans in the fall but decide you don’t like the plan once your coverage begins in January, you can switch back to Original Medicare or another Medicare Advantage plan before March 31.
You can also change plans anytime you qualify for a Special Enrollment Period. Visit Medicare.gov for more information about Special Enrollment Periods.
Original Medicare is Medicare Parts A and B. It is administered by the federal government.
Medicare Advantage (Part C) is provided by private insurance companies, like Blue Cross NC. It covers the same types of care as Medicare Parts A and B but lowers your share of the costs when you use doctors and hospitals that are part of the plan’s network.
Yes. You’ll need to be enrolled in Original Medicare (Parts A and B) to be eligible for a Medicare Advantage plan.
Once you become a Blue Medicare HMO or Blue Medicare PPO member, you transfer the administration of your Medicare benefits to the plan. This means you maintain your status as a Medicare beneficiary, plus gain the enhanced coverage available through your health plan. You will receive a member ID card that you will present when using your benefits. You should present this card when using your pharmacy benefits as well. You are still responsible for paying your Medicare Part B premium.
Yes. If you join Blue Medicare HMO or Blue Medicare PPO, you can keep your military benefits.
Yes. Starting in plan year 2021, people with End Stage Renal Disease can enroll in Medicare Advantage.
You can search for doctors in the Blue Cross NC network using our Find a Doctor tool. You can also use the tool to search for in-network pharmacies and medical facilities.
As a Medicare Advantage member, you are entitled to receive a one-time Welcome to Medicare exam within the first 12 months of enrollment in Medicare Part B. The Welcome to Medicare exam offers an opportunity for your doctor to review your medical and personal history, conduct several simple measurements and screenings related to your well-being, and outline a plan for future preventive services.
One annual routine physical exam is covered at no cost to you. This includes baseline measurements such as blood pressure, height and weight, review of risk factors, and certain diagnostic tests that include complete blood count and urinalysis. Use of your primary care physician (PCP) on record is highly encouraged.
If you have been enrolled in Medicare Part B for more than 12 months, you will want to schedule this as an Annual Wellness Visit. It’s important to schedule the correct visit so it can be covered correctly.
Blue Medicare HMO and Blue Medicare PPO plans cover eligible emergency services for you in or out of the service area. If you have a medical emergency, go to the nearest medical facility or call 911. Emergency services require a copayment, but it will be waived if you are admitted to the hospital on an inpatient basis within 48 hours. Please contact your primary care physician (PCP) or Blue Medicare HMO or Blue Medicare PPO within 48 hours so your PCP can coordinate follow-up care.
If you have a PPO plan, you can use your out-of-network benefits for your doctor and may pay more. Otherwise, your plan will notify you if your doctor leaves the plan network, and you’ll be able to choose a new doctor.
If you permanently move out of state, you’ll need to sign up for a Medicare Advantage plan in that state, or switch to Original Medicare.
You’ll need to be enrolled in Original Medicare (Parts A and B) to be eligible for a Medicare Supplement plan.
Supplement plans help cover costs not covered by Original Medicare, such as coinsurance, copays and deductibles.
Compare Medicare Supplement plan: https://www.bcbsnc.com/assets/shopper/public/quote/medicare/index.htm#/getstarted
Blue Medicare Supplement benefits can be used coast-to-coast with any provider or facility that accepts Medicare.
If your Medicare Supplement plan is from Blue Cross NC you can keep your plan if you move to a different state.
Medicare Part B covers a limited number of outpatient prescription drugs under limited conditions. Drugs covered under Part B are drugs you’d have administered in a doctor’s office or hospital outpatient setting, such as a flu vaccine. You can view a list of these drugs at Medicare.gov.
For medications you’d administer yourself, including maintenance medications and drugs prescribed by a doctor to take at home, you’d want to consider a Medicare Rx (Part D) plan or a Medicare Advantage plan that includes prescription drug coverage.
You’ll need to be enrolled in either Part A or Part B of Original Medicare to be eligible for a Medicare Rx (Part D) plan.
If you’re enrolled in Medicare Advantage without prescription coverage, you cannot enroll in a standalone Medicare Rx plan. If you’d like a Medicare Advantage plan plus drug coverage, be sure to choose a Medicare Advantage plan that includes drug coverage.
Medicare has designed a “standard benefit.” Companies may offer additional enhanced plans, but they must offer a standard benefit package that is at least equal in value to Medicare’s standard benefit as follows:
$435 deductible – You will be responsible for 100% of the first $435 in total prescription drug costs in each calendar year before your prescription drug benefit begins.
25% coinsurance – After the first $435, you will be responsible for 25% of the total cost of your prescription drugs. The Plan will pay 75% of your total drug costs until they reached a total of $4,020.
100% coinsurance – After your total drug costs reach $4,020, you will be responsible for all of your prescription drug costs until you reach an annual out-of-pocket limit of $6,550. This is referred to as the “coverage gap.”
5% coinsurance – After your total out-of-pocket costs reach $6,550, you will pay very little for prescription drugs. You will pay only 5% (or $3.70 generic/$9.20 brand name>, whichever is greater) for prescription drugs and your insurance company will pay the rest.
Each plan provider will establish its own formulary, or list of prescription drugs, that it will cover. Although formularies must meet certain requirements set by Medicare, they still differ by plan.1
Generally speaking, Medicare prescription drug coverage covers drugs that meet the following criteria:
They must be available only by prescription
They must be approved by the Food and Drug Administration
They must be used and sold in the United States
They must be used for a medically necessary indication
Specifically, coverage will include:
Certain medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs and gauze).
Certain drugs, or classes of drugs, will not be covered because they are excluded by law, such as over the counter medicines like aspirin.
To learn which drugs are covered by Blue Cross NC Blue Medicare Rx (PDP) plans, search our formulary: https://www.myprime.com/en/medicines.html#find-medicine
1. You can search for specific drugs online: https://www.myprime.com/en/medicines.html#find-medicine.
2. If you’re not a Blue Cross NC member, contact Sales at 1-800-665-8037.
3. Current Blue Cross NC members can call Customer Service at 1-888-247-4142 (TTY: 711). We are available for phone calls 8 a.m. to 8 p.m. daily.
You have the convenience of ordering your prescriptions from the mail order pharmacy, AllianceRx Walgreens Prime, https://www.alliancerxwp.com/. You can purchase up to a 90-day supply through mail order, and your medications will be delivered directly to your home. Depending on your plan, there may be savings available to you if you use the mail option.
No. Only drugs purchased in the United States are eligible for Medicare prescription drug coverage.
If your in-network pharmacy is part of a large national chain, your prescription may be covered under the in-network rate. Otherwise, you would use your out-of-network pharmacy benefits to fill a prescription out-of-state. International pharmacies are not eligible for Medicare prescription drug coverage.
Because Medicare Rx plans are based on the plan’s formulary and pharmacy network, you’d need to enroll in a Medicare Rx plan in your new state.
Congress designed Medicare prescription drug coverage on an annual enrollment cycle. This means that each year, you will have the option to re-enroll in your existing Medicare prescription drug coverage plan or change plans between October 15 and December 7 each year.
If you qualify for a Special Enrollment Period (SEP), you can change your Medicare Rx plan.
You may also have another opportunity during the year to switch plans, under limited circumstances. For example, if you move out of your plan’s service area, you’ll have an opportunity to choose another plan that serves your new area.