2020 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Anthem MediBlue Preferred (HMO) | ||||
Location: | Licking, Ohio Click to see other locations | ||||
Plan ID: | H3655 - 040 - 0 Click to see other plans | ||||
Member Services: | 1-855-690-7796 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 |
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Email a copy of the Anthem MediBlue Preferred (HMO) benefit details
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— 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): | $4,900 | ||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,845 drugs | Browse the Anthem MediBlue Preferred (HMO) Formulary | |||
This plan has 6 drug tiers.
See cost-sharing for all pharmacies and tiers.
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Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $4.00 | $10.00 | $42.00 | $95.00 | 33% |
• Number of Drugs per Tier: | 300 | 592 | 935 | 1227 | 701 |
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 Licking, Ohio: | 1,153 members | ||||
Number of Members enrolled in this plan in (H3655 - 040): | 93,464 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 3 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 3 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Base 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 — | |||||
** Base Plan ** | |||||
Premium | |||||
• Health plan premium: $0 | |||||
• Drug plan premium: $0 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• 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) | |||||
• $4,900 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: $40 copay per visit (authorization and referral required) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0-250 copay (authorization and referral required) | |||||
• Lab services: $0-10 copay (authorization and referral required) | |||||
• Diagnostic radiology services (e.g., MRI): $130-250 copay (authorization and referral required) | |||||
• Outpatient x-rays: $50-110 copay (authorization and referral required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 copay per visit (always covered) | |||||
• Urgent care: $35 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• $310 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• $0-285 copay 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: $300 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) | |||||
Dialysis | |||||
• 20% coinsurance | |||||
Hearing | |||||
• Hearing exam: $40 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 | |||||
Vision | |||||
• 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) | |||||
Transportation | |||||
• $0 copay (limits apply, authorization required) | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $0-40 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: $14.00 | |||||
• Deductible: | |||||
Package #2 | |||||
• Monthly Premium: $25.00 | |||||
• 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: $42.00 | |||||
• 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 |