Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H7728-006-000
Plan Organization Anthem Blue Cross and Blue Shield
Plan Type Local PPO
Plan Name Anthem MediBlue Access Basic (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5 Stars
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $150.00
Annual Drug Deductible $150.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Gap Coverage Yes
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Endodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Extractions No - - - Not covered
Diagnostic services No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes Yes 40%
Lab services - Out-of-Network Yes Yes 40%
Outpatient x-rays - In-Network Yes Yes $50-110
Diagnostic tests and procedures - Out-of-Network Yes Yes 40%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - Out-of-Network Yes Yes $60 per visit
Primary - In-Network - - $10 per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 per visit (always covered)
Urgent care - - - - $35 per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care No Out-of-Network Yes Yes $60
Foot exams and treatment - In-Network Yes Yes $0-40
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes Out-of-Network Yes Yes 20%
Hearing aids Yes In-Network Yes No $0 copay
Hearing exam - In-Network Yes Yes $40
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $393 per day for days 1 through 5 $0 per day for days 6 through 90
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 40% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 40% per item
Diabetes supplies - Out-of-Network Yes - 40% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 40%
Other Part B drugs - Out-of-Network Yes - 40%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes Yes $60
Inpatient hospital - psychiatric - In-Network Yes No $275 per day for days 1 through 6 $0 per day for days 7 through 90
Outpatient individual therapy visit - Out-of-Network Yes Yes $60
Outpatient group therapy visit - Out-of-Network Yes Yes $60
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes Yes $60
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes Yes 50% per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 40%
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes In-Network No No $0 copay
Fluoride treatment No - - - Not covered
Oral exam Yes Out-of-Network No No 20%
Dental x-ray(s) No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes Yes $60
Physical therapy and speech and language therapy visit - In-Network Yes Yes $40
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglasses (frames and lenses) No - - - Not covered
Eyeglass frames No - - - Not covered
Other No - - - Not covered
Contact lenses No - - - Not covered
Eyeglass lenses No - - - Not covered
Routine eye exam Yes Out-of-Network No No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 50% per stay
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $300
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $1,000 annual deductible
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network $6,700 In-network

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Preventive dental Monthly Premium
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium
Eyewear Monthly Premium
Preventive dental Monthly Premium
Package #3
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium
Eyewear Monthly Premium
Preventive dental Monthly Premium
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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