Anthem MediBlue Service (PPO)
Anthem MediBlue Service (PPO) H4909-023 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: H4909-023.
$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: H4909-023.
Anthem MediBlue Service (PPO) H4909-023 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: H4909-023.
$0.00
Monthly Premium
Kentucky Counties Served
Adair
Allen
Anderson
Barren
Boone
Boyd
Bullitt
Floyd
Henderson
Jefferson
Ballard
Bath
Bell
Bourbon
Boyle
Bracken
Breckinridge
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Claiborne
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henry
Hickman
Hopkins
Jackson
Jessamine
Johnson
Kenton
Knott
Knox
Larue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Livingston
Logan
Lyon
Madison
Magoffin
Marion
Marshall
Martin
Mason
Mccracken
Mccreary
Mclean
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pickett
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
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: 30% coinsurance |
| Specialty Doctor Visit | In-Network: $45.00 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: $290.00 copay |
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: $45.00 - $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 - $45.00 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: $196.00 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: $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. $3,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year. Out-of-Network: Medicare Covered Hearing Exam: 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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