2021 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Anthem MediBlue Extra (HMO) | ||||
Location: | Dearborn, Indiana Click to see other locations | ||||
Plan ID: | H3447 - 024 - 0 Click to see other plans | ||||
Member Services: | 1-855-251-8827 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 Extra (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $29.60 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $445 (Tier 1 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $4,130 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,704 drugs | Browse the Anthem MediBlue Extra (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 | $9.00 | $37.00 | $90.00 | 25% |
• Number of Drugs per Tier: | 302 | 607 | 940 | 1055 | 710 |
Plan's Pharmacy Search: | https://shop.anthem.com/medicare | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Dearborn, Indiana: | 51 members | ||||
Number of Members enrolled in this plan in Indiana: | 5,630 members | ||||
Number of Members enrolled in this plan in (H3447 - 024): | 5,751 members | ||||
Plan’s Summary Star Rating: | 3.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 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: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |
$29.60 | $0.00 | $29.60 | $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 | $7.40 | $14.80 | $22.20 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $7.40 | $14.80 | $22.20 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Health plan premium: $0 | |||||
• Drug plan premium: $29.60 | |||||
• 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: $445.00 annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $6,700 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: $0 copay | |||||
• Specialist: $30 copay per visit (authorization and referral required) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0-90 copay (authorization and referral required) | |||||
• Lab services: $0-10 copay (authorization and referral required) | |||||
• Diagnostic radiology services (e.g., MRI): $90-150 copay (authorization and referral required) | |||||
• Outpatient x-rays: $50-90 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 | |||||
• $290 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• $0-245 copay per visit (authorization and referral required) | |||||
Skilled Nursing Facility | |||||
• $0 per day for days 1 through 20 $184 per day for days 21 through 100 (authorization required) | |||||
Preventive care | |||||
• $0 copay | |||||
Ground ambulance | |||||
• $250 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: $260 per day for days 1 through 6 $0 per day for days 7 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) | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required) | |||||
• Diabetes supplies: $0 copay (authorization required) | |||||
Hearing | |||||
• Hearing exam: $30 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: $0 copay (limits apply) | |||||
• Diagnostic services: $0 copay (limits apply) | |||||
• Restorative services: $0 copay (limits apply) | |||||
• Endodontics: $0 copay (limits apply) | |||||
• Periodontics: $0 copay (limits apply) | |||||
• Extractions: $0 copay (limits apply) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply) | |||||
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: $0-30 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: $15.00 | |||||
• Deductible: | |||||
Package #2 | |||||
• Monthly Premium: $26.00 | |||||
• Deductible: | |||||
Package #3 | |||||
• Monthly Premium: $51.00 | |||||
• Deductible: |