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2020 Medicare Advantage Plan Benefit Details for the Anthem MediBlue Plus (HMO) - H9525-008-0

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2020 Medicare Advantage Plan Details
Medicare Plan Name:Anthem MediBlue Plus (HMO)
Location:McCracken, Kentucky     Click to see other locations
Plan ID:H9525 - 008 - 0     Click to see other plans
Member Services:1-855-558-1439 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 Plus (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$4,020
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$5,300
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,845 drugsBrowse the Anthem MediBlue Plus (HMO) 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:
Number of Drugs per
Plan's Pharmacy Search:https://shop.anthem.com/medicare
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 McCracken, Kentucky:496 members
Number of Members enrolled in this plan in Kentucky:42,994 members
Number of Members enrolled in this plan in (H9525 - 008):42,107 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: 4 out of 5 Stars.
Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS): 100%
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 —
** Base Plan **
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $5,300 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $5 copay per visit
• Specialist: $45 copay per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0-225 copay (authorization and referral required)
• Lab services: $0-25 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI): $180-225 copay (authorization and referral required)
• Outpatient x-rays: $50-130 copay (authorization and referral required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $40 copay per visit (always covered)
Inpatient hospital coverage
• $270 per day for days 1 through 8
$0 per day for days 9 through 90 (authorization required)
Outpatient hospital coverage
• $0 copay or 20% coinsurance per visit (authorization and referral required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$178 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $260 copay
Rehabilitation services
• Occupational therapy visit: $40 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $40 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $265 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient group therapy visit: $40 copay (authorization and referral required)
• Outpatient individual therapy visit: $40 copay (authorization and referral required)
Opioid treatment program services
• In-network: $40.00 copay (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): $0 copay or 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
• 20% coinsurance
• Hearing exam: $45 copay (authorization and referral required)
• Fitting/evaluation: $0 copay (limits apply, authorization and referral required)
• Hearing aids: $0 copay (limits apply, authorization required)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: $0 copay (limits apply)
• Dental x-ray(s): $0 copay (limits apply)
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
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered (authorization required)
• $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $0-45 copay (authorization and referral required)
• Routine foot care: $0 copay (authorization and referral required)
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)
Package #1
• Monthly Premium: $16.00
• Deductible:
Package #2
• Monthly Premium: $22.00
• Deductible:
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• Therapeutic Massage: Some coverage
• Alternative Therapies: Not covered
Package #3
• Monthly Premium: $49.00
• Deductible:
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 transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Some coverage
• Bathroom Safety Devices: Some coverage
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Some coverage
• 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: Some coverage
• 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

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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
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