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Anthem MediBlue Extra (HMO)

Anthem Blue Cross and Blue Shield
Anthem MediBlue Extra (HMO) H3447-024 Plan Details
4 out of 5 stars

Anthem MediBlue Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H3447-024.

$21.10
Monthly Premium

Anthem MediBlue Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H3447-024.

Anthem Blue Cross and Blue Shield
Anthem MediBlue Extra (HMO) H3447-024 Plan Details
4 out of 5 stars

Anthem MediBlue Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H3447-024.

$21.10
Monthly Premium

Indiana Counties Served

Adams Bartholomew Benton Boone Clark Daviess Jasper Allen Blackford Brown Carroll Cass Clay Clinton Crawford Dearborn Decatur Dekalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush Scott Shelby Spencer St Joseph Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $505
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:
$0.00 copay
Specialty Doctor Visit
In-Network:
$30.00 copay
Inpatient Hospital Care
In-Network:
Days 1-7: $290.00 per day, per admission / Days 8-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
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: $250.00 copay Per Trip
Air Ambulance: $250.00 copay

Health Care Services and Medical Supplies

Anthem MediBlue Extra (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 - $10.00 copay
X-Rays: $50.00 - $90.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 - $90.00 copay
Diagnostic Radiological Services: $90.00 - $150.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days 1-6: $260.00 per day, per admission / Days 7-90: $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: $245.00 copay
Observation Services: $245.00 copay
Ambulatory Surgical Center: $200.00 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 $170 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 - $30.00 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), 1 fluoride treatment(s) every year.

Medicare Covered Dental: $0.00 copay
Comprehensive Dental Services: $0.00 copay
This plan covers up to a $250.00 allowance for covered comprehensive dental services every quarter.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:
Medicare Covered Eye Exam: $0.00 - $30.00 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 $200.00 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: $30.00 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. $3,000.00 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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