Anthem MediBlue Access (PPO)
Anthem MediBlue Access (PPO) H8552-029 Plan Details
Anthem MediBlue Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross Life and Health Insurance Company.
Plan ID: H8552-029.
$30.00
Monthly Premium
Anthem MediBlue Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross Life and Health Insurance Company.
Plan ID: H8552-029.
Anthem MediBlue Access (PPO) H8552-029 Plan Details
Anthem MediBlue Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross Life and Health Insurance Company.
Plan ID: H8552-029.
$30.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $370 |
| 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: $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: 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 - $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: 40% coinsurance X-Rays: 40% coinsurance Therapeutic Radiological Services: 40% 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 1-7: $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: 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) 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 Routine Eye Wear: $0.00 copay This plan covers up to $200.00 for eyeglasses or contact lenses every year. Out-of-Network: Medicare Covered Eye Exam: 40% coinsurance Routine Eye Exam: $0.00 copay Medicare Covered Eye Wear: $0.00 copay Routine 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 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. $3,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year. Out-of-Network: Medicare Covered Hearing Exam: 40% coinsurance 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 |
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 |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $370 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $370 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
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