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Anthem MediBlue Essential (HMO)

Anthem Blue Cross and Blue Shield
Anthem MediBlue Essential (HMO) H5422-008 Plan Details
3 out of 5 stars

Anthem MediBlue Essential (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H5422-008.

$38.00
Monthly Premium

Anthem MediBlue Essential (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H5422-008.

Anthem Blue Cross and Blue Shield
Anthem MediBlue Essential (HMO) H5422-008 Plan Details
3 out of 5 stars

Anthem MediBlue Essential (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H5422-008.

$38.00
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 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: $3450
Out-of-Network: N/A
Initial Coverage Limit $4660
Catastrophic Coverage Limit $7,400
Primary Care Doctor Visit
In-Network:
$10.00 copay
Specialty Doctor Visit
In-Network:
$50.00 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
Urgent Care
Urgent Care: $40.00 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: $265.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem MediBlue Essential (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 - $25.00 copay
X-Rays: $50.00 - $125.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 - $175.00 copay
Diagnostic Radiological Services: $225.00 - $250.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days 1-5: $295.00 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: $300.00 copay
Observation Services: $300.00 copay
Ambulatory Surgical Center: $275.00 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 $57 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 - $50.00 copay
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
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 $1,500.00 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 - $50.00 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 $100.00 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: $50.00 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
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