Anthem MediBlue + Kroger (HMO)
Anthem MediBlue + Kroger (HMO) H3447-039 Plan Details
Anthem MediBlue + Kroger (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem HealthKeepers.
Plan ID: H3447-039.
$0.00
Monthly Premium
Anthem MediBlue + Kroger (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem HealthKeepers.
Plan ID: H3447-039.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $150 |
| Out of Pocket Max |
In-Network: $4900 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: $0.00 copay |
| Specialty Doctor Visit | In-Network: $35.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-6: $285.00 per day, per admission / Days 7-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days |
| Urgent Care | Urgent Care: $50.00 copay |
| Emergency Room Visit | Emergency Care: $90.00 copay 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 $100,000.00 per year. |
| Ambulance Transportation | Ground Ambulance: $300.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Anthem MediBlue + Kroger (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: $0.00 copay |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay X-Rays: $45.00 - $105.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 - $100.00 copay Diagnostic Radiological Services: $295.00 - $345.00 copay |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Days 1-5: $300.00 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: $40.00 copay |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $345.00 copay Observation Services: $345.00 copay Ambulatory Surgical Center: $295.00 copay |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $200 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: $35.00 copay |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental Services: $0.00 copay This plan covers: 2 oral exam(s), 2 cleaning(s), 1 dental X-ray(s) every year. Medicare Covered Dental: $0.00 copay Comprehensive Dental Services: $0.00 copay This plan covers up to a $2,000.00 allowance for covered comprehensive dental services every year. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare Covered Eye Exam: $0.00 - $35.00 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: $35.00 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(s) and hearing aid fitting/evaluation(s) every year. $2,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan 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 |
Prescription Drug Costs and Coverage
The Anthem MediBlue + Kroger (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1, 2, 3 and 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $150 (excludes Tiers 1, 2, 3 and 6) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $150 (excludes Tiers 1, 2, 3 and 6) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $150 (excludes Tiers 1, 2, 3 and 6) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Select Care Drugs |
|
Find Medicare Advantage Plans
Visit MedicareAdvantage.com to compare multiple Medicare Advantage plans, side by side.
