Anthem MediBlue Preferred (HMO)
Anthem MediBlue Preferred (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H3655-045.
$0.00
Monthly Premium
Anthem MediBlue Preferred (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H3655-045.
Ohio Counties Served
Adams
Allen
Ashland
Ashtabula
Athens
Auglaize
Belmont
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Jefferson
Lake
Lawrence
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Meigs
Mercer
Miami
Monroe
Montgomery
Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren
Washington
Wayne
Williams
Wood
Wyandot
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $0 |
Out of Pocket Max |
In-Network: $4200 Out-of-Network: N/A |
Initial Coverage Limit | $4430 |
Catastrophic Coverage Limit | $7,050 |
Primary Care Doctor Visit | In-Network: $5.00 copay |
Specialty Doctor Visit | In-Network: $35.00 copay |
Inpatient Hospital Care | In-Network: Days 1-7: $310.00 per day, per admission / Days 8-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days |
Urgent Care | Urgent Care: $30.00 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: $260.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Anthem MediBlue Preferred (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 - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 - $250.00 copay Diagnostic Radiological Services: $130.00 - $250.00 copay |
Home Health Care | In-Network: $0.00 copay |
Mental Health Inpatient Care | In-Network: Days 1-5: $300.00 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: $285.00 copay Observation Services: $285.00 copay Ambulatory Surgical Center: $245.00 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 $62 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 - $35.00 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: $188.00 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: 50% coinsurance for Restorative and Extraction services. 70% coinsurance for Endodontics, Periodontics, Crowns, and Denture services. This plan covers up to a $1,000.00 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 - $35.00 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 $175.00 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: $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. $3,000.00 maximum plan benefit for hearing aids 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 |