Anthem MediBlue Access Basic (PPO)
Anthem MediBlue Access Basic (PPO) H7728-006 Plan Details
Anthem MediBlue Access Basic (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H7728-006.
$0.00
Monthly Premium
Anthem MediBlue Access Basic (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H7728-006.
Anthem MediBlue Access Basic (PPO) H7728-006 Plan Details
Anthem MediBlue Access Basic (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H7728-006.
$0.00
Monthly Premium
Georgia Counties Served
Appling
Baker
Baldwin
Barrow
Bartow
Bryan
Clarke
Spalding
Paulding
Atkinson
Bacon
Banks
Ben Hill
Bibb
Bleckley
Brantley
Bulloch
Burke
Butts
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clayton
Clinch
Cobb
Coffee
Columbia
Coweta
Crawford
Crisp
Dawson
Dekalb
Dodge
Dooly
Douglas
Effingham
Elbert
Emanuel
Evans
Fannin
Forsyth
Franklin
Fulton
Gilmer
Glascock
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Laurens
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
Mcduffie
Mcintosh
Meriwether
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Richmond
Rockdale
Russell
Schley
Screven
Stephens
Stewart
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Wilcox
Wilkes
Wilkinson
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: $5.00 copay Out-of-Network: $50.00 copay |
| Specialty Doctor Visit | In-Network: $40.00 copay Out-of-Network: $60.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-6: $295.00 per day, per admission / Days 7-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Urgent Care | Urgent Care: $35.00 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 Access Basic (PPO) 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 Out-of-Network: Medicare Covered Chiropractic Services: $60.00 copay |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 40% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance Out-of-Network: 40% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 - $10.00 copay X-Rays: $30.00 - $90.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 - $140.00 copay Diagnostic Radiological Services: $150.00 - $250.00 copay Out-of-Network: Lab Services: 40% coinsurance X-Rays: 40% coinsurance Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: 40% coinsurance Diagnostic Radiological Services: 40% coinsurance |
| Home Health Care | In-Network: $0.00 copay Out-of-Network: 40% coinsurance |
| Mental Health Inpatient Care | In-Network: Days 1-6: $275.00 per day, per admission / Days 7-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: $60.00 copay |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $325.00 copay Observation Services: $325.00 copay Ambulatory Surgical Center: $275.00 copay Out-of-Network: Outpatient Hospital - Surgery: 50% coinsurance Observation Services: 50% coinsurance Ambulatory Surgical Center: 50% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $35 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 - $40.00 copay Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. Out-of-Network: Medicare Covered Podiatry Services: $60.00 copay Routine Foot Care: $60.00 copay |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day Out-of-Network: 40% coinsurance per stay |
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 $1,000.00 allowance for covered comprehensive dental services every year. Out-of-Network: Medicare Covered Dental Services: $0.00 copay Preventive Dental: 20% coinsurance Comprehensive Dental: $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 - $40.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. $69.00 maximum eye exam coverage amount. Medicare Covered Eye Wear: $0.00 copay Out-of-Network: Medicare Covered Eye Exam: $60.00 copay Routine Eye Exam: $0.00 copay Medicare Covered Eye Wear: $60.00 copay |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare Covered Hearing Exam: $40.00 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. $59.00 maximum plan benefit for routine hearing exam(s) every year. $2,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year. Out-of-Network: Medicare Covered Hearing Exam: $60.00 copay Routine Hearing Exam: 20% coinsurance for routine hearing exam(s). |
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 Out-of-Network: 40% coinsurance |
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