Anthem MediBlue Service (PPO) H7093-001 is a 2023 Medicare Advantage Plan or Part-C by Anthem Blue Cross and Blue Shield available to residents in Indiana. This plan does not provide extra prescription drug (Part-D) coverage. Anthem Blue Cross and Blue Shield Anthem MediBlue Service (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,700 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $6,700 out-of-pocket. This can be an extremely nice safety net.

Anthem Blue Cross and Blue Shield works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Anthem MediBlue Service (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Anthem Blue Cross and Blue Shield and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Anthem Blue Cross and Blue Shield except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Indiana.

2023 Anthem Blue Cross and Blue Shield Medicare Advantage Plan Overview

What type of plan is Anthem MediBlue Service (PPO)

Anthem MediBlue Service (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network, but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

How much does Anthem MediBlue Service (PPO) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Anthem Blue Cross and Blue Shield charges a $0 premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Anthem MediBlue Service (PPO) by Anthem Blue Cross and Blue Shield MOOP is $6,700. Once you spend $6,700 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

2023 Summary of Benefits

The benefit information provided is a summary of what Anthem MediBlue Service (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Anthem Blue Cross and Blue Shield helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

---

Contact lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Eyeglass frames

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Eyeglass lenses

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

---

Eyeglasses (frames and lenses)

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

---

Other

Vision	Not covered

---

Routine eye exam

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Upgrades

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Out-of-Network Transportation	$0 copay
In-Network Transportation	$0 copay
Out-of-Network Skilled Nursing Facility	30% per stay
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100

---

Occupational therapy visit

Out-of-Network Rehabilitation services	30% coinsurance
In-Network Rehabilitation services	$40 copay

---

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	30% coinsurance

---

Cleaning

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

---

Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

---

Fluoride treatment

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

---

Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

---

In-Network Preventive care	$0 copay
Out-of-Network Preventive care	30% coinsurance
Out-of-Network Outpatient hospital coverage	30% coinsurance per visit
In-Network Outpatient hospital coverage	$0-275 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	Yes

---

Inpatient hospital - psychiatric

In-Network Mental health services	$295 per day for days 1 through 6 $0 per day for days 7 through 90
Out-of-Network Mental health services	30% per stay

---

Outpatient group therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	30% coinsurance

---

Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	30% coinsurance

---

Outpatient individual therapy visit

Out-of-Network Mental health services	30% coinsurance
In-Network Mental health services	$40 copay

---

Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	30% coinsurance

---

Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

---

Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

---

Diabetes supplies

In-Network Medical equipment/supplies	$0 copay
Out-of-Network Medical equipment/supplies	30% coinsurance per item

---

Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	0-20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

---

Prosthetics (e.g., braces, artificial limbs)

Out-of-Network Medical equipment/supplies	30% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

---

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$10,000 In and Out-of-network $6,700 In-network
Out-of-Network Inpatient hospital coverage	30% per stay
In-Network Inpatient hospital coverage	$295 per day for days 1 through 7 $0 per day for days 8 through 90

---

Fitting/evaluation

Out-of-Network Hearing	20% coinsurance
In-Network Hearing	$0 copay

---

Hearing aids

Out-of-Network Hearing	$0 copay
In-Network Hearing	$0 copay

---

Hearing exam

Out-of-Network Hearing	30% coinsurance
In-Network Hearing	$45 copay

---

Health plan deductible	$0
In-Network Ground ambulance	$290 copay
Out-of-Network Ground ambulance	$290 copay

---

Foot exams and treatment

Out-of-Network Foot care (podiatry services)	30% coinsurance
In-Network Foot care (podiatry services)	$0-45 copay

---

Routine foot care

In-Network Foot care (podiatry services)	$0 copay
Out-of-Network Foot care (podiatry services)	30% coinsurance

---

Emergency

Emergency care/Urgent care	$90 copay per visit (always covered)

---

Urgent care

Emergency care/Urgent care	$25 copay per visit (always covered)

---

Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	30% coinsurance per visit

---

Specialist

Out-of-Network Doctor visits	30% coinsurance per visit
In-Network Doctor visits	$45 copay per visit

---

Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$180-275 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

---

Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0-100 copay

---

Lab services

Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0-50 copay

---

Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$50-110 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

---

Diagnostic services

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

---

Endodontics

Out-of-Network Comprehensive dental	$0 copay
In-Network Comprehensive dental	$0 copay

---

Extractions

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

---

Non-routine services

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

---

Periodontics

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

---

Prosthodontics, other oral/maxillofacial surgery, other services

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

---

Restorative services

Out-of-Network Comprehensive dental	$0 copay
In-Network Comprehensive dental	$0 copay

---

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Anthem MediBlue Service (PPO) requires you to live in that plan’s service area. The service area is listed below:

Go to top

Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.