Anthem MediBlue Service (PPO)
Anthem MediBlue Service (PPO) H4909-021 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: H4909-021.
$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: H4909-021.
Anthem MediBlue Service (PPO) H4909-021 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: H4909-021.
$0.00
Monthly Premium
Missouri Counties Served
Adair
Audrain
Barry
Barton
Bollinger
Boone
Butler
Callaway
Camden
Cape Girardeau
Carter
Cedar
Chariton
Christian
Clark
Cole
Cooper
Crawford
Dade
Dallas
Dent
Douglas
Dunklin
Franklin
Gasconade
Greene
Hickory
Howard
Howell
Iron
Jasper
Jefferson
Knox
Laclede
Lawrence
Lewis
Lincoln
Linn
Macon
Madison
Maries
Marion
McDonald
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Oregon
Osage
Ozark
Pemiscot
Perry
Phelps
Pike
Polk
Pulaski
Putnam
Ralls
Randolph
Reynolds
Ripley
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Warren
Washington
Wayne
Webster
Wright
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $6700 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | In-Network: $20.00 copay Out-of-Network: 30% coinsurance |
| Specialty Doctor Visit | In-Network: $50.00 copay Out-of-Network: 30% coinsurance |
| Inpatient Hospital Care | In-Network: Days 1-7: $295.00 per day, per admission / Days 8-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 30% coinsurance per stay |
| Urgent Care | Urgent Care: $25.00 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: $290.00 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: 30% coinsurance |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 30% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance Out-of-Network: 30% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 - $50.00 copay X-Rays: $50.00 - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 - $100.00 copay Diagnostic Radiological Services: $180.00 - $275.00 copay Out-of-Network: Lab Services: 30% coinsurance X-Rays: 30% coinsurance Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: 30% coinsurance Diagnostic Radiological Services: 30% coinsurance |
| Home Health Care | In-Network: $0.00 copay Out-of-Network: 30% coinsurance |
| Mental Health Inpatient 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 Out-of-Network: 30% coinsurance per stay |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 30% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $275.00 copay Observation Services: $275.00 copay Ambulatory Surgical Center: $245.00 copay Out-of-Network: Outpatient Hospital - Surgery: 30% coinsurance Observation Services: 30% coinsurance Ambulatory Surgical Center: 30% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $50.00 - $100.00 copay Out-of-Network: 30% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $150 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. Out-of-Network: Medicare Covered Podiatry Services: 30% coinsurance Routine Foot Care: 30% coinsurance |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $188.00 per day Out-of-Network: 30% 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: $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 - $40.00 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 $200.00 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: $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: $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. $59.00 maximum plan benefit for routine hearing exam(s) every year. $3,000.00 maximum plan benefit for hearing aids every year. Out-of-Network: Medicare Covered Hearing Exam: 30% coinsurance 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: 30% coinsurance |
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