Anthem MediBlue Value (HMO)

Anthem Blue Cross
Anthem MediBlue Value (HMO) H0544-107 Plan Details
3.5 out of 5 stars

Anthem MediBlue Value (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0544-107.

$0.00
Monthly Premium

Anthem MediBlue Value (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0544-107.

Anthem Blue Cross
Anthem MediBlue Value (HMO) H0544-107 Plan Details
3.5 out of 5 stars

Anthem MediBlue Value (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0544-107.

$0.00
Monthly Premium

California Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3400
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:
$0.00 copay
Specialty Doctor Visit
In-Network:
$15.00 copay
Inpatient Hospital Care
In-Network:
Days 1-5: $75.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Urgent Care
Urgent Care: $0.00 copay
Emergency Room Visit
Emergency Care: $90.00 copay
Copay waived if admitted to hospital within 24 Hours
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: $100.00 copay Per Trip
Air Ambulance: $100.00 copay

Health Care Services and Medical Supplies

Anthem MediBlue Value (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: $0.00 copay
Routine Chiropractic Services: $0.00 copay unlimited visits each year
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: 20% coinsurance
Durable Medical Eqipment (DME)
In-Network:
$0.00 copay applies for DME less than $500.00. 20% coinsurance applies for DME greater than or equal to $500.00.
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay
Diagnostic Radiological Services: $0.00 - $100.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days 1-5: $75.00 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: $15.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $125.00 copay
Observation Services: $125.00 copay
Ambulatory Surgical Center: $0.00 copay
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $30.00 copay
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: $15.00 copay
Routine Foot Care: $15.00 copay
6 routine foot care visits each year.
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $75.00 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), 2 dental X-ray(s) every year.

Medicare Covered Dental: $15.00 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 - $15.00 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: $0.00 copay

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