Anthem MediBlue Access (PPO)

Anthem Blue Cross Life and Health Insurance Company
Anthem MediBlue Access (PPO) H8552-020 Plan Details
3.5 out of 5 stars

Anthem MediBlue Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H8552-020.

$172.00
Monthly Premium

Anthem MediBlue Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H8552-020.

Anthem Blue Cross Life and Health Insurance Company
Anthem MediBlue Access (PPO) H8552-020 Plan Details
3.5 out of 5 stars

Anthem MediBlue Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H8552-020.

$172.00
Monthly Premium

California Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $370
Out of Pocket Max In-Network: $6700
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:
$10.00 copay
Out-of-Network:
$30.00 copay
Specialty Doctor Visit
In-Network:
$35.00 copay
Out-of-Network:
$50.00 copay
Inpatient Hospital Care
In-Network:
Days 1-7: $175.00 per day, per admission / Days 8-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
40% coinsurance per stay
Urgent Care
Urgent Care: $30.00 copay
Emergency Room Visit
Emergency Care: $90.00 copay
Copay waived if admitted to hospital within 24 Hours
Ambulance Transportation
Ground Ambulance: $325.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem MediBlue Access (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: $50.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Out-of-Network:
30% coinsurance
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Out-of-Network:
30% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 - $5.00 copay
X-Rays: $25.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 - $75.00 copay
Diagnostic Radiological Services: $75.00 copay
Out-of-Network:
Lab Services: 50% coinsurance
X-Rays: 50% coinsurance
Therapeutic Radiological Services: 50% coinsurance
Outpatient Diagnostic Procedures/Tests: 50% coinsurance
Diagnostic Radiological Services: 50% coinsurance
Home Health Care
In-Network:
$0.00 copay
Out-of-Network:
40% coinsurance
Mental Health Inpatient Care
In-Network:
Days 1-7: $175.00 per day, per admission / Days 8-90: $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: $20.00 copay
Out-of-Network:
$50.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $175.00 copay
Observation Services: $175.00 copay
Ambulatory Surgical Center: $100.00 copay
Out-of-Network:
Outpatient Hospital - Surgery: 40% coinsurance
Observation Services: 40% coinsurance
Ambulatory Surgical Center: 40% coinsurance
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $20.00 copay
Out-of-Network:
40% coinsurance
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $35.00 copay
Out-of-Network:
Medicare Covered Podiatry Services: $50.00 copay
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $140.00 per day
Out-of-Network:
15% 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: 1 oral exam(s), 1 cleaning(s) every year.

Medicare Covered Dental: $35.00 copay
Out-of-Network:
Medicare Covered Dental Services: 40% coinsurance
Preventive Dental: 20% coinsurance

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. $69.00 maximum eye exam coverage amount.
Medicare Covered Eye Wear: $0.00 copay
Out-of-Network:
Medicare Covered Eye Exam: 40% coinsurance
Routine Eye Exam: $0.00 copay
Medicare Covered Eye Wear: $0.00 copay

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
Out-of-Network:
Medicare Covered Hearing Exam: 40% coinsurance

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

Prescription Drug Costs and Coverage

The Anthem MediBlue Access (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $370 (excludes Tiers 1 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $370 (excludes Tiers 1 and 6)
Preferred Generic
  • Preferred retail $4.00
  • Standard retail $9.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $370 (excludes Tiers 1 and 6)
Preferred Generic
  • Preferred retail $8.00
  • Standard retail $18.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $370 (excludes Tiers 1 and 6)
Preferred Generic
  • Preferred retail $12.00
  • Standard retail $27.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00