Anthem MediBlue Service (PPO)

3 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: H4909-021-000

$0.00 Monthly Premium

Missouri 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 Missouri 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 visit
30% coinsurance
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 services
Medicare Covered Chiropractic Services: 30% coinsurance
Diabetes supplies, training, nutrition therapy and monitoring
30% coinsurance
Durable medical equipment (DME)In-Network:
20% coinsurance
Diagnostic tests, lab and radiology services, and X-rays
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 careIn-Network:
$0.00 copay
Mental health inpatient care
30% coinsurance per stay
Mental health outpatient care
30% coinsurance
Outpatient services/surgery
Outpatient Hospital - Surgery: 30% coinsurance
Observation Services: 30% coinsurance
Ambulatory Surgical Center: 30% coinsurance
Outpatient substance abuse care
30% coinsurance
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
Medicare Covered Podiatry Services: 30% coinsurance
Routine Foot Care: 30% coinsurance
Skilled Nursing Facility (SNF) care
30% coinsurance per stay

Dental Benefits

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

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

Coverage Details
Vision benefitsIn-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.

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
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
30% coinsurance

When reviewing Missouri 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 Missouri 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

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 Saint Charles Saint Francois Saint Louis Saint Louis City Sainte Genevieve Schuyler Scotland Scott Shannon Shelby Stoddard Stone Sullivan Taney Texas Warren Washington Wayne Webster Wright
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