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2020 Medicare Advantage Plan Benefit Details for the Anthem MediBlue ESRD (PPO C-SNP) - H8552-028-0


2020 Medicare Advantage Plan Details
Medicare Plan Name:Anthem MediBlue ESRD (PPO C-SNP)
Location:San Luis Obispo, California
Plan ID:H8552 - 028 - 0     Click to see other plans
Member Services:1-844-648-9540 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
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Email a copy of the Anthem MediBlue ESRD (PPO C-SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$16.40 (see Plan Premium Details below)
Annual Deductible:$130 (Tier 1 and 6 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$4,020
Health Plan Type:Local PPO
Special Needs Plan (SNP)
Eligibility Requirement:
End-stage Renal Disease Requiring Dialysis
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,845 drugsBrowse the Anthem MediBlue ESRD (PPO C-SNP) Formulary
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:
$1.00$6.00$42.00$95.0030%
Number of Drugs per
  Tier:
3005929281233702
Plan's Pharmacy Search:https://shop.anthem.com/medicare/ca
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 020115   PCN: IS   See BIN/PCNs for all plans
Number of Members enrolled in this plan in San Luis Obispo, California:16 members
Number of Members enrolled in this plan in (H8552 - 028):1,050 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: 2 out of 5 Stars.
Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
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$4.10$8.20$12.30
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $16.40
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $1,408 per year for some in-network and out-of-network services.
• Other health plan deductibles: In-network: No
• Drug plan deductible: $130.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $10,000 In and Out-of-network
$6,700 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $0 copay
• Primary Out-of-network: $0 copay
• Specialist In-network: $0 copay or 20% coinsurance per visit (authorization and referral required)
• Specialist Out-of-network: $0 copay or 20% coinsurance per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: 20% coinsurance (authorization and referral required)
• Diagnostic tests and procedures Out-of-network: 20% coinsurance (authorization and referral required)
• Lab services In-network: 20% coinsurance (authorization and referral required)
• Lab services Out-of-network: 20% coinsurance (authorization and referral required)
• Diagnostic radiology services (e.g., MRI) In-network: 20% coinsurance (authorization and referral required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 20% coinsurance (authorization and referral required)
• Outpatient x-rays In-network: 20% coinsurance (authorization and referral required)
• Outpatient x-rays Out-of-network: 20% coinsurance (authorization and referral required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $25 copay per visit (always covered)
Inpatient hospital coverage
• In-network: In 2020 the amounts for each benefit period are:
$1,408 deductible for days 1 through 60
$352 copay per day for days 61 through 90 (authorization required)
• Out-of-network: In 2020 the amounts for each benefit period are:
$1,408 deductible for days 1 through 60
$352 copay per day for days 61 through 90 (authorization required)
Outpatient hospital coverage
• In-network: 20% coinsurance per visit (authorization and referral required)
• Out-of-network: 20% coinsurance per visit (authorization and referral required)
Skilled Nursing Facility
• In-network: In 2020 the amounts for each benefit period are:
$0 copay for days 1 through 20
$176.00 copay per day for days 21 through 100 (authorization required)
• Out-of-network: In 2020 the amounts for each benefit period are:
$0 copay for days 1 through 20
$176.00 copay per day for days 21 through 100 (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: 20% coinsurance
Ground ambulance
• In-network: 20% coinsurance
• Out-of-network: 20% coinsurance
Rehabilitation services
• Occupational therapy visit In-network: 20% coinsurance (authorization and referral required)
• Occupational therapy visit Out-of-network: 20% coinsurance (authorization and referral required)
• Physical therapy and speech and language therapy visit In-network: 20% coinsurance (authorization and referral required)
• Physical therapy and speech and language therapy visit Out-of-network: 20% coinsurance (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric In-network: In 2020 the amounts for each benefit period are:
$1,408 deductible for days 1 through 60
$352 copay per day for days 61 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: In 2020 the amounts for each benefit period are:
$1,408 deductible for days 1 through 60
$352 copay per day for days 61 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: 20% coinsurance (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: 20% coinsurance (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist In-network: 20% coinsurance (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 20% coinsurance (authorization and referral required)
• Outpatient group therapy visit In-network: $0 copay (authorization and referral required)
• Outpatient group therapy visit Out-of-network: 20% coinsurance (authorization and referral required)
• Outpatient individual therapy visit In-network: $0 copay (authorization and referral required)
• Outpatient individual therapy visit Out-of-network: 20% coinsurance (authorization and referral required)
Opioid treatment program services
• In-network: 20% coinsurance (authorization and referral required)
• Out-of-network: 20% coinsurance (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: $0 copay or 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 20% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay (authorization required)
• Diabetes supplies Out-of-network: 20% coinsurance per item (authorization required)
Dialysis
• 20% coinsurance or $0.00 copay
Hearing
• Hearing exam In-network: 20% coinsurance (authorization and referral required)
• Hearing exam Out-of-network: 20% coinsurance (authorization and referral required)
• Fitting/evaluation: Not covered
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Oral exam Out-of-network: 20% coinsurance (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: 20% coinsurance (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: 20% coinsurance (limits apply)
Comprehensive dental
• Non-routine services In-network: $0 copay (limits apply)
• Non-routine services Out-of-network: 20% coinsurance (limits apply)
• Diagnostic services In-network: $0 copay (limits apply)
• Diagnostic services Out-of-network: 20% coinsurance (limits apply)
• Restorative services In-network: $0 copay (limits apply)
• Restorative services Out-of-network: 20% coinsurance (limits apply)
• Endodontics In-network: $0 copay (limits apply)
• Endodontics Out-of-network: 20% coinsurance (limits apply)
• Periodontics In-network: $0 copay (limits apply)
• Periodontics Out-of-network: 20% coinsurance (limits apply)
• Extractions In-network: $0 copay (limits apply)
• Extractions Out-of-network: 20% coinsurance (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services In-network: $0 copay (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services Out-of-network: 20% coinsurance (limits apply)
Vision
• Routine eye exam In-network: $0 copay (limits apply)
• Routine eye exam Out-of-network: $0 copay (limits apply)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply)
• Eyeglass frames In-network: $0 copay (limits apply)
• Eyeglass frames Out-of-network: $0 copay (limits apply)
• Eyeglass lenses In-network: $0 copay (limits apply)
• Eyeglass lenses Out-of-network: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• In-network: $0 copay (limits apply, authorization required)
• Out-of-network: 50% coinsurance (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment In-network: $0 copay or 20% coinsurance (authorization and referral required)
• Foot exams and treatment Out-of-network: 20% coinsurance (authorization and referral required)
• Routine foot care In-network: $0 copay (authorization and referral required)
• Routine foot care Out-of-network: 20% coinsurance (authorization and referral required)
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 20% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 20% coinsurance (authorization required)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency: Not covered
• Fitness Benefit: Not covered
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered




Tips & Disclaimers
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  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
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  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
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  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.