Anthem MediBlue Service (PPO)
Anthem MediBlue Service (PPO) H4909-020 Plan Details
Anthem MediBlue Service (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H4909-020.
$0.00
Monthly Premium
Anthem MediBlue Service (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H4909-020.
Anthem MediBlue Service (PPO) H4909-020 Plan Details
Anthem MediBlue Service (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H4909-020.
$0.00
Monthly Premium
Virginia Counties Served
Albemarle
Alleghany
Amelia
Amherst
Bland
Botetourt
Buchanan
Chesterfield
Covington City
Hampton City
Isle Of Wight
Appomattox
Augusta
Bath
Bedford
Bristol City
Brunswick
Buckingham
Buena Vista City
Campbell
Caroline
Carroll
Charles City
Charlottesville City
Chesapeake City
Clarke
Colonial Heights City
Craig
Culpeper
Cumberland
Danville City
Dickenson
Dinwiddie
Emporia City
Essex
Fauquier
Floyd
Fluvanna
Franklin
Franklin City
Frederick
Fredericksburg City
Galax City
Giles
Gloucester
Goochland
Grayson
Greene
Greensville
Halifax
Hanover
Harrisonburg City
Henrico
Henry
Highland
Hopewell City
James City
Jefferson
King And Queen
King George
King William
Lancaster
Lee
Lexington City
Loudoun
Louisa
Lunenburg
Lynchburg City
Madison
Manassas City
Manassas Park City
Martinsville City
Mathews
Mecklenburg
Middlesex
Montgomery
Nelson
New Kent
Newport News City
Norfolk City
Northampton
Northumberland
Norton City
Nottoway
Orange
Page
Patrick
Petersburg City
Pittsylvania
Poquoson City
Portsmouth City
Powhatan
Prince Edward
Prince George
Pulaski
Radford
Rappahannock
Richmond
Richmond City
Roanoke
Roanoke City
Rockbridge
Rockingham
Russell
Salem
Scott
Shenandoah
Smyth
Southampton
Spotsylvania
Stafford
Staunton City
Suffolk City
Surry
Sussex
Tazewell
Virginia Beach City
Warren
Washington
Waynesboro City
Westmoreland
Williamsburg City
Winchester City
Wise
Wythe
York
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: $0.00 copay Out-of-Network: $35.00 copay |
| Specialty Doctor Visit | In-Network: $45.00 copay Out-of-Network: $60.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-5: $290.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 35% coinsurance per stay |
| Urgent Care | Urgent Care: $45.00 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: $350.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Anthem MediBlue Service (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: 35% coinsurance |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 35% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance Out-of-Network: 35% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 - $15.00 copay X-Rays: $50.00 - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 - $140.00 copay Diagnostic Radiological Services: $130.00 - $200.00 copay Out-of-Network: Lab Services: 35% coinsurance X-Rays: 35% coinsurance Therapeutic Radiological Services: 35% coinsurance Outpatient Diagnostic Procedures/Tests: 35% coinsurance Diagnostic Radiological Services: 35% coinsurance |
| Home Health Care | In-Network: $0.00 copay Out-of-Network: 35% coinsurance |
| Mental Health Inpatient Care | In-Network: Days 1-5: $290.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 35% coinsurance per stay |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 35% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $300.00 copay Observation Services: $300.00 copay Ambulatory Surgical Center: $245.00 copay Out-of-Network: Outpatient Hospital - Surgery: 35% coinsurance Observation Services: 35% coinsurance Ambulatory Surgical Center: 35% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 35% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $50 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: $45.00 copay Out-of-Network: Medicare Covered Podiatry Services: $60.00 copay |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day Out-of-Network: 35% 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), 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 $2,000.00 allowance for covered comprehensive dental services every year. Out-of-Network: Medicare Covered Dental Services: $0.00 copay Preventive Dental: 20% coinsurance 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 - $45.00 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 $100.00 for eyeglasses or contact lenses every year. Out-of-Network: Medicare Covered Eye Exam: $60.00 copay Routine Eye Exam: $0.00 copay Medicare Covered Eye Wear: $60.00 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: $45.00 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. $1,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year. Out-of-Network: Medicare Covered Hearing Exam: $60.00 copay 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: 35% coinsurance |
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