Anthem MediBlue Dual Access (PPO D-SNP)

Anthem Blue Cross and Blue Shield
Anthem MediBlue Dual Access (PPO D-SNP) H4909-028 Plan Details
3 out of 5 stars

Anthem MediBlue Dual Access (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H4909-028.

$0.00
Monthly Premium

Anthem MediBlue Dual Access (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H4909-028.

Anthem Blue Cross and Blue Shield
Anthem MediBlue Dual Access (PPO D-SNP) H4909-028 Plan Details
3 out of 5 stars

Anthem MediBlue Dual Access (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H4909-028.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8300
Out-of-Network: N/A
Initial Coverage Limit $4660
Catastrophic Coverage Limit $7,400
Primary Care Doctor Visit
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay
Specialty Doctor Visit
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay
Inpatient Hospital Care
In-Network:
$0.00 copay per stay
Out-of-Network:
$0.00 copay per stay
Urgent Care
Urgent Care: $0.00 copay
Emergency Room Visit
Emergency Care: $0.00 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: $0.00 copay Per Trip
Air Ambulance: $0.00 copay

Health Care Services and Medical Supplies

Anthem MediBlue Dual Access (PPO D-SNP) 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: $0.00 copay
Out-of-Network:
Medicare Covered Chiropractic Services: $0.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Out-of-Network:
$0.00 copay
Durable Medical Eqipment (DME)
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 copay
Therapeutic Radiological Services: $0.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 copay
Diagnostic Radiological Services: $0.00 copay
Out-of-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 copay
Therapeutic Radiological Services: $0.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 copay
Diagnostic Radiological Services: $0.00 copay
Home Health Care
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
$0.00 copay per stay
Out-of-Network:
$0.00 copay per stay
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $0.00 copay
Out-of-Network:
$0.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $0.00 copay
Observation Services: $0.00 copay
Ambulatory Surgical Center: $0.00 copay
Out-of-Network:
Outpatient Hospital - Surgery: $0.00 copay
Observation Services: $0.00 copay
Ambulatory Surgical Center: $0.00 copay
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $0.00 copay
Out-of-Network:
$0.00 copay
Over-the-counter (OTC) Items
You can receive a $125.00 monthly spending allowance to buy eligible over-the-counter (OTC) products and healthy groceries at participating stores near you. OTC products and select healthy groceries are also available online.
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $0.00 copay
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
Out-of-Network:
Medicare Covered Podiatry Services: $0.00 copay
Routine Foot Care: $0.00 copay
Skilled Nursing Facility Care
In-Network:
$0.00 copay per stay
Out-of-Network:
$0.00 copay 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), 1 fluoride treatment(s) every year.

Medicare Covered Dental: $0.00 copay
Comprehensive Dental Services: $0.00 copay
This plan covers up to a $4,000.00 allowance for covered comprehensive dental services every year.
Out-of-Network:
Medicare Covered Dental Services: $0.00 copay
Preventive Dental: $0.00 copay
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 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 $400.00 for eyeglasses or contact lenses every year.
Out-of-Network:
Medicare Covered Eye Exam: $0.00 copay
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: $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(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: $0.00 copay
Routine Hearing Exam: $0.00 copay 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:
$0.00 copay