Anthem MediBlue Service (PPO)

4.5 out of 5 stars* for plan year 2023
$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: H4036-022-000

$0.00 Monthly Premium

Ohio Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Ohio Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible($1.00)
Out-of-pocket maximum$6,700.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:
$0.00 copay
Specialty doctor visitIn-Network:
$45.00 copay
Inpatient hospital careIn-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
Urgent careUrgent Care: $25.00 copay
Emergency room visitEmergency 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 transportationGround Ambulance: $290.00 copay Per Trip
Air Ambulance: $290.00 copay

Health Care Services and Medical Supplies

Anthem MediBlue Service (PPO) covers a range of additional benefits. Learn more about Anthem MediBlue Service (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:
Medicare Covered Chiropractic Services: $20.00 copay
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:
Diabetic Supplies: $0.00 copay
Durable medical equipment (DME)In-Network:
20% coinsurance
Diagnostic tests, lab and radiology services, and X-rays
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
Out-of-Network:
30% coinsurance
Mental health inpatient careIn-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
Mental health outpatient care
Out-of-Network:
30% coinsurance
Outpatient services/surgery
Out-of-Network:
Outpatient Hospital - Surgery: 30% coinsurance
Observation Services: 30% coinsurance
Ambulatory Surgical Center: 30% coinsurance
Outpatient substance abuse careIn-Network:
Individual and Group Sessions: $45.00 - $100.00 copay
Over-the-counter itemsThis 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
Out-of-Network:
Medicare Covered Podiatry Services: 30% coinsurance
Routine Foot Care: 30% coinsurance
Skilled Nursing Facility (SNF) careIn-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-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.

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefits
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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefits
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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programs
Out-of-Network:
30% coinsurance

When reviewing Ohio Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Ohio that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

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 Knox 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
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