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Medicare Supplement Disclaimer: Neither Blue Cross and Blue Shield of North Carolina nor its agents are endorsed by or affiliated with the United States government or the federal Medicare program.

Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

A formulary applies for all plans that include Medicare prescription drug coverage.

Preventive care is covered at 100% with your primary care provider, at a county health clinic, or at CVS Minute Clinics.

You must use the plan's providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Blue Cross NC will be responsible for the costs.

Beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

Mail order is available; please see Summary of Benefits for more details.

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 in-network contract amount.

You must continue to pay the Medicare Part B premium in addition to your plan premium.

Caution: Policy benefits are limited to those approved by Medicare for payment.

If you go to a physician not participating in Medicare you may be responsible for the difference in the approved Medicare charge and the billed amount. Private contracts between you and a provider are excluded from Medicare and Medicare Supplemental payments.

When you enroll in an attained-age plan, your rates will increase as you age. Our rates will only increase due to age when you move from one age band to the next. In addition, rate adjustments will also be due to medical inflation or overall claims experience. Rates are subject to change June 1 of each year and are guaranteed for 12 months. Any change in rate will be preceded by a 30-day notice. Members will not be singled out for premium increases based on their individual health. Medicare policies that are attained-age should be compared to issue-age rated policies. Premiums for issue-age policies do not increase due to age as the insured ages.

The Silver&Fit® program is a value-added service that is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH) to members of Blue Cross NC's Blue Medicare Supplement plans. The program is not part of a member's policy or benefits, and is not available on our Plan F-HD. The program may be changed or discontinued at any time. Additional fees may apply and results are not guaranteed. You should consult with your doctor before taking part in a fitness program. All programs and services are not available in all areas. Silver&Fit and the Silver&Fit logo are trademarks of ASH and are used with permission herein. 

This is only a summary of benefits describing the policies' most important features. The policy is the insurance contract. You must read the policy itself to understand all the rights and duties of both you and your insurance company. These policies may not fully cover all of your medical costs. Neither BCBSNC nor its agents are affiliated with Medicare. Plan A: BMS A, 12/17; Plan B: BMS B, 12/17; Plan C: BMS C, 12/17; Plan D: BMS D, 12/17; Plan F: BMS F, 12/17; Plan High-Ded F: BMS HDF, 12/17; Plan G: BMS G, 12/17; Plan K: BMS K, 12/17; Plan L: BMS L, 12/17; Plan M: BMS M, 12/17; Plan N: BMS N, 12/17. 

If you enroll within 30 days following your 65th birthday, or if you have 6 months of continuous prior coverage, the 6-month waiting period for pre-existing conditions will be waived. Pre-existing conditions are conditions for which medical advice was given, or treatment was recommended by or received from a physician within six months before the effective date of coverage. If you wait until after the deadline to enroll, you may have a waiting period for pre-existing conditions and may have to complete a medical questionnaire.

Except the Blue Medicare HMO Medical Only plan, which does not provide drug coverage.

Blue Cross NC is one of the World's Most Ethical Companies (2012, 2013, 2014, 2016). Ethisphere Institute reviewed nominations from companies in more than 100 countries and 36 industries.

Basic Blue® Rx (PDP) (S6986-002) only.

MII Life, Inc., a Medicare contractor, is an independent licensee of the Blue Cross® and Blue Shield® Association and the underwriter for Basic Blue® Rx, a prescription drug plan. Enrollment in Basic Blue Rx depends on contract renewal. Each Blue Cross and/or Blue Shield plan is an independent licensee of the Blue Cross and Blue Shield Association. Medicare beneficiaries may also enroll in Basic Blue® Rx through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Drug pricing information on this website is intended as an educational tool and is not a promise as to the price we will offer in the future. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. This information is not a complete description of benefits. Contact the plan for more information. Other are available in our network. Medicare has neither reviewed nor endorsed this information. For a variety of reasons (e.g., because you visit an out-of-network pharmacy), actual pricing may vary. You must continue to pay your Medicare Part B premium. This is not a complete list of drugs covered by our plan. For a complete listing, please call TTY 1-877-376-2185 TTY 711 or visit www.basicbluerx.com The formulary and pharmacy network may change at any time. You will receive notice when necessary. This is not a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

S6986_092818_B01_NC Approved 10/10/17

Out-of-network/non-contracted providers are under no obligation to treat Blue Cross NC members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365  days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Once you have been billed $183 of Medicare-Approved amounts for covered services your Part B deductible will have been met for the calendar year.

This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $2240 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

You will pay one-half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5240 each calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

This amount counts toward your annual out-of-pocket limit. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.

You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2620 each calendar year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

Important Information

• Legal Information and Disclaimers
• Policies regarding privacy, usage, fraud and abuse, and web accessibility
• Fraud and Abuse Report Form (pdf)
• Medicare Complaint Form (external site)

To view PDF documents, you need to download and install Adobe Acrobat Reader (external site) on your computer.

Links marked with an (external site) icon indicate that you're now leaving bcbsnc.com and Blue Cross and Blue Shield of North Carolina's plan information. The site you're going to is either a third-party vendor contracted with Blue Cross NC to provide services or an external website independent of Blue Cross NC.

The information on this page is current as of 10/1/2017.

Y0079_7833 CMS Approved 10172017

U12448, 10/2017