2018 Medicare Advantage Plan Details | |||||
---|---|---|---|---|---|
Medicare Plan Name: | Anthem MediBlue Local (HMO) | ||||
Location: | Chesterfield, Virginia Click to see other locations | ||||
Plan ID: | H3447 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-888-326-3584 TTY users 711 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
||||
Email a copy of the Anthem MediBlue Local (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,750 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,191 drugs | Browse the Anthem MediBlue Local (HMO) Formulary | |||
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $9.50 | $40.00 | $85.00 | 33% |
• Number of Drugs per Tier: | 51 | 1662 | 358 | 437 | 570 |
Plan's Pharmacy Search: | http://www.anthem.com/medicare | ||||
Plan Offers Mail Order? | No | ||||
Number of Members enrolled in this plan in Chesterfield, Virginia: | 779 members | ||||
Number of Members enrolled in this plan in Virginia: | 2,494 members | ||||
Number of Members enrolled in this plan in (H3447 - 001): | 2,619 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 4 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |
$0.00 | $0.00 | $0.00 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $0.00 | $0.00 | $0.00 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $0 | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $3,400 In-network | |||||
Optional supplemental benefits | |||||
• Yes | |||||
Inpatient hospital coverage | |||||
• $300 for days 1 through 5 $0 for days 6 through 90 $0 for days 91 through 364 | |||||
Outpatient hospital coverage | |||||
• $200 per visit | |||||
Preventive care | |||||
• $0 copay | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Doctor visits | |||||
• Primary: $0 copay | |||||
• Specialist: $0-35 per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $100 per visit (always covered) | |||||
• Urgent care: $20 per visit (always covered) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0 copay | |||||
• Lab services: $0 copay | |||||
• Diagnostic radiology services (e.g., MRI): $0-150 | |||||
• Outpatient x-rays: $0 | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Mental health services | |||||
• $300 for days 1 through 5 $0 for days 6 through 90 $0 for days 91 through 150 | |||||
Skilled Nursing Facility | |||||
• $0 for days 1 through 20 $125 for days 21 through 100 | |||||
Ambulance | |||||
• $250 | |||||
Transportation | |||||
• $0 copay | |||||
Mental health services | |||||
• Outpatient group therapy visit with a psychiatrist: $0-35 | |||||
• Outpatient individual therapy visit with a psychiatrist: $0-35 | |||||
• Outpatient group therapy visit: $0-25 | |||||
• Outpatient individual therapy visit: $0-25 | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $20 | |||||
• Physical therapy and speech and language therapy visit: $0-20 | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $0-35 | |||||
• Routine foot care: $0-35 | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): 0-20% per item | |||||
• Diabetes supplies: 20% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 20% | |||||
• Other Part B drugs: 0-20% | |||||
** Benefits Services ** | |||||
Hearing | |||||
• Hearing exam: $0 copay | |||||
• Fitting/evaluation: $0 copay | |||||
• Hearing aids: $0 copay | |||||
Preventive dental | |||||
• Oral exam: Not covered | |||||
• Cleaning: Not covered | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): Not covered | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: $0 copay | |||||
• Other: Not covered | |||||
• Contact lenses: $0 copay | |||||
• Eyeglasses (frames and lenses): Not covered | |||||
• Eyeglass frames: $0 copay | |||||
• Eyeglass lenses: $20 | |||||
• Upgrades: Not covered | |||||
** Optional Supplemental Benefits ** | |||||
Package #1 | |||||
• Comprehensive dental services, Preventive dental services | |||||
• Monthly Premium: $35.00 | |||||
• Deductible: N/A |