2023 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Anthem MediBlue Access Plus (PPO) | ||||
Location: | Dane, Wisconsin Click to see other locations | ||||
Plan ID: | H4036 - 020 - 0 Click to see other plans | ||||
Member Services: | 1-855-690-7802 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 Access Plus (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $195 (Tier 1, 2 and 6 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $4,660 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,700 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,680 drugs | Browse the Anthem MediBlue Access Plus (PPO) Formulary | |||
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $5.00 | $15.00 | $42.00 | $95.00 | 30% |
• Number of Drugs per Tier: | 270 | 580 | 860 | 1065 | 728 |
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 Dane, Wisconsin: | 149 members | ||||
Number of Members enrolled in this plan in Wisconsin: | 8,854 members | ||||
Number of Members enrolled in this plan in (H4036 - 020): | 8,927 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 5 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 | |
$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: $195.00 annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $8,950 In and Out-of-network $4,700 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 In-network: $0 copay | |||||
• Primary Out-of-network: $35 copay per visit | |||||
• Specialist In-network: $35 copay per visit (authorization required) | |||||
• Specialist Out-of-network: $55 copay per visit (authorization required) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures In-network: $0-95 copay (authorization required) | |||||
• Diagnostic tests and procedures Out-of-network: 20% coinsurance (authorization required) | |||||
• Lab services In-network: $0-10 copay (authorization required) | |||||
• Lab services Out-of-network: 20% coinsurance (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) In-network: $95-195 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) Out-of-network: 20% coinsurance (authorization required) | |||||
• Outpatient x-rays In-network: $50-100 copay (authorization required) | |||||
• Outpatient x-rays Out-of-network: 20% coinsurance (authorization required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 copay per visit (always covered) | |||||
• Urgent care: $30 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• In-network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
• Out-of-network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• In-network: $0-295 copay per visit (authorization required) | |||||
• Out-of-network: 20% coinsurance per visit (authorization required) | |||||
Skilled Nursing Facility | |||||
• In-network: $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) | |||||
• Out-of-network: 45% per stay (authorization required) | |||||
Preventive care | |||||
• In-network: $0 copay | |||||
• Out-of-network: 40% coinsurance | |||||
Ground ambulance | |||||
• In-network: $310 copay | |||||
• Out-of-network: $310 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit In-network: $35 copay (authorization required) | |||||
• Occupational therapy visit Out-of-network: $60 copay (authorization required) | |||||
• Physical therapy and speech and language therapy visit In-network: $35 copay (authorization required) | |||||
• Physical therapy and speech and language therapy visit Out-of-network: $60 copay (authorization required) | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric In-network: $295 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
• Inpatient hospital - psychiatric Out-of-network: $295 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist In-network: $35 copay (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist Out-of-network: $60 copay (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist In-network: $35 copay (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $60 copay (authorization required) | |||||
• Outpatient group therapy visit In-network: $35 copay (authorization required) | |||||
• Outpatient group therapy visit Out-of-network: $60 copay (authorization required) | |||||
• Outpatient individual therapy visit In-network: $35 copay (authorization required) | |||||
• Outpatient individual therapy visit Out-of-network: $60 copay (authorization required) | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 0-20% coinsurance per item (authorization required) | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 40% 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: 40% coinsurance per item (authorization required) | |||||
• Diabetes supplies In-network: $0 copay | |||||
• Diabetes supplies Out-of-network: 40% coinsurance per item | |||||
Hearing | |||||
• Hearing exam In-network: $35 copay (authorization required) | |||||
• Hearing exam Out-of-network: $55 copay (authorization required) | |||||
• Fitting/evaluation In-network: $0 copay (limits apply, authorization required) | |||||
• Fitting/evaluation Out-of-network: 20% coinsurance (limits apply, authorization required) | |||||
• Hearing aids In-network: $0 copay (limits apply, authorization required) | |||||
• Hearing aids Out-of-network: $0 copay (limits apply, authorization required) | |||||
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 In-network: $0 copay (limits apply) | |||||
• Fluoride treatment Out-of-network: 20% coinsurance (limits apply) | |||||
• 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: 50% coinsurance (limits apply, authorization required) | |||||
• Non-routine services Out-of-network: 50-70% coinsurance (limits apply, authorization required) | |||||
• Diagnostic services In-network: $0 copay (limits apply, authorization required) | |||||
• Diagnostic services Out-of-network: 50-70% coinsurance (limits apply, authorization required) | |||||
• Restorative services In-network: 50% coinsurance (limits apply, authorization required) | |||||
• Restorative services Out-of-network: 50-70% coinsurance (limits apply, authorization required) | |||||
• Endodontics In-network: 70% coinsurance (limits apply, authorization required) | |||||
• Endodontics Out-of-network: 50-70% coinsurance (limits apply, authorization required) | |||||
• Periodontics In-network: 70% coinsurance (limits apply, authorization required) | |||||
• Periodontics Out-of-network: 50-70% coinsurance (limits apply, authorization required) | |||||
• Extractions In-network: 50% coinsurance (limits apply, authorization required) | |||||
• Extractions Out-of-network: 50-70% coinsurance (limits apply, authorization required) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services In-network: 70% coinsurance (limits apply, authorization required) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services Out-of-network: 50-70% coinsurance (limits apply, authorization required) | |||||
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 In-network: $0 copay (limits apply) | |||||
• Upgrades Out-of-network: $0 copay (limits apply) | |||||
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 | |||||
• Over-the-counter drug benefits: Some coverage | |||||
• Meals for short duration: Not covered | |||||
• 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: 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 | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• In-network: $0 copay (limits apply) | |||||
• Out-of-network: $0 copay (limits apply) | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment In-network: $0-35 copay (authorization required) | |||||
• Foot exams and treatment Out-of-network: $55 copay (authorization required) | |||||
• Routine foot care In-network: $0 copay (authorization required) | |||||
• Routine foot care Out-of-network: $55 copay (authorization required) | |||||
Medicare Part B drugs | |||||
• Chemotherapy In-network: 20% coinsurance (authorization required) | |||||
• Chemotherapy Out-of-network: 40% coinsurance (authorization required) | |||||
• Other Part B drugs In-network: 20% coinsurance (authorization required) | |||||
• Other Part B drugs Out-of-network: 40% coinsurance (authorization required) | |||||
Package #1 | |||||
• Monthly Premium: $23.00 | |||||
• Deductible: N/A | |||||
Package #2 | |||||
• Monthly Premium: $36.00 | |||||
• Deductible: N/A | |||||
Package #3 | |||||
• Monthly Premium: $57.00 | |||||
• Deductible: N/A |