Anthem I Carelon Medicare Advantage (HMO)
Anthem I Carelon Medicare Advantage (HMO) H3447-001 Plan Details
Anthem I Carelon Medicare Advantage (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem HealthKeepers
Plan ID: H3447-001
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$0.00
Monthly Premium
Anthem I Carelon Medicare Advantage (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem HealthKeepers
Plan ID: H3447-001
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Virginia Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3850 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: $0.00 copay |
| Specialty Doctor Visit | In-Network: $0.00 copay - $20.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-5: $325.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days |
| Urgent Care | Urgent Care: $20.00 copay |
| Emergency Room Visit | Emergency Care: $120.00 copay Copay waived if admitted to hospital within 24 hours Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $50,000.00 per year. |
| Ambulance Transportation | Ground Ambulance: $250.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Anthem I Carelon Medicare Advantage (HMO) 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: Medicare Covered Chiropractic Services: $20.00 copay |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: 20% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: Your cost is $0.00 copay when the value of the DME is $499.99 or less. Your cost is 20% coinsurance when the value of the DME is $500.00 or more. |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay X-Rays: $0.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay Diagnostic Radiological Services: $0.00 copay - $150.00 copay |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Days 1-5: $325.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $0.00 copay - $25.00 copay |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $325.00 copay Observation Services: $325.00 copay Ambulatory Surgical Center: $200.00 copay |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $30.00 copay |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $100 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year. |
| Podiatry Services | In-Network: Medicare Covered Podiatry Services: $0.00 copay - $20.00 copay Routine Foot Care: $20.00 copay 4 routine foot care visit(s) each year. |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $125.00 per day |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive and Comprehensive Dental Combined Allowance This plan covers up to $1,000 for covered preventive and comprehensive dental services every year. Medicare Covered Dental: $0.00 copay - $35.00 copay Preventive Dental Services: $0.00 copay Comprehensive Dental Services: $0.00 copay |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare Covered Eye Exam: $0.00 copay - $20.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $200.00 for eyeglasses or contact lenses every year. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare Covered Hearing Exam: $0.00 copay Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount. This plan covers 1 routine hearing exam every year. $300.00 maximum plan benefit for over-the-counter hearing aids OR 1 routine hearing aid fitting evaluation and a $3,000.00 maximum plan benefit for prescribed hearing aids every year. |
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 |
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