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2020 Anthem MediBlue ESRD (PPO C-SNP) in Madera, California

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Anthem MediBlue ESRD (PPO C-SNP) (H8552 - 028) in Madera, California .

This plan is administered by ANTHEM BLUE CROSS LIFE AND HEALTH INS COMPANY.  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Anthem MediBlue ESRD (PPO C-SNP) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The Anthem MediBlue ESRD (PPO C-SNP) has a monthly premium of $16.40. That is $196.80 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $16.40 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local PPO plan.

Plan Membership and Plan Ratings
The Anthem MediBlue ESRD (PPO C-SNP) (H8552 - 028) currently has 1,050 members. There are 21 members enrolled in this plan in Madera, California.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 3.5 stars. The detail CMS plan carrier ratings are as follows:
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $130 deductible. However, formulary drugs on Tier 1 and 6 are excluded from the $130 deductible and have first dollar coverage (or a $0 deductible). So, you are 100% responsible for the first $130 in medication costs for drugs not on the excluded tiers. After you have met the deductible, the Anthem MediBlue ESRD (PPO C-SNP) will share the costs of your medications with you (see cost-sharing below). The maximum deductible for 2020 is $435, but this plan (Anthem MediBlue ESRD (PPO C-SNP)) has a $130. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.

The following information is about the Anthem MediBlue ESRD (PPO C-SNP) formulary (or drug list). There are 3781 drugs on the Anthem MediBlue ESRD (PPO C-SNP) formulary. Click here to browse the Anthem MediBlue ESRD (PPO C-SNP) Formulary.
 
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $130, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Anthem MediBlue ESRD (PPO C-SNP)’s formulary is divided into 6 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Preferred Generic) contains 300 drugs and has a co-payment of $1.00.
  • Tier 2 (Generic) contains 592 drugs and has a co-payment of $6.00.
  • Tier 3 (Preferred Brand) contains 928 drugs and has a co-payment of $42.00.
  • Tier 4 (Non-Preferred Drug) contains 1,233 drugs and has a co-payment of $95.00.
  • Tier 5 (Specialty Tier) contains 702 drugs and has a co-insurance of 30% of the drug cost.
  • Tier 6 (Select Care Drugs) contains drugs and has a co-payment of $0.00.
Click here to browse the Anthem MediBlue ESRD (PPO C-SNP) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (Anthem MediBlue ESRD (PPO C-SNP)) offers Coverage in the gap, however Medicare has not specified the details of the gap coverage.

The Anthem MediBlue ESRD (PPO C-SNP) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** 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
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.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.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • 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.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • 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.