Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5422-007-000
Plan Organization Anthem Blue Cross and Blue Shield
Plan Type Local HMO
Plan Name Anthem MediBlue Dual Advantage (HMO D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
Overall Star Rating 3.5 Stars
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part D Basic Premium $25.30
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $25.30
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $6.30
Monthly Part D Premium 50% Assistance $12.60
Monthly Part D Premium 25% Assistance $19.00
Part D Drug Deductible $435.00
Annual Drug Deductible $435.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Gap Coverage Y
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Endodontics Yes - No No $0
Restorative services Yes - No No $0
Diagnostic services Yes - No No $0
Non-routine services Yes - No No $0
Periodontics Yes - No No $0
Extractions Yes - No No $0
Prosthodontics, other oral/maxillofacial surgery, other services Yes - No No $0
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes Yes $0 copay
Outpatient x-rays - - Yes Yes $0 copay
Lab services - - Yes Yes $0 copay
Diagnostic tests and procedures - - Yes Yes $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes Yes $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care No - Yes Yes $0
Foot exams and treatment - - Yes Yes $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Prosthetics (e.g., braces, artificial limbs) - - Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - $0 copay
Diabetes supplies - - Yes - $0 copay
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - $0 copay
Other Part B drugs - - Yes - $0 copay
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - - Yes Yes $0 copay
Outpatient group therapy visit with a psychiatrist - - Yes Yes $0 copay
Outpatient individual therapy visit with a psychiatrist - - Yes Yes $0 copay
Inpatient hospital - psychiatric - - Yes No $0 copay
Outpatient individual therapy visit - - Yes Yes $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglass frames Yes - No No $0
Eyeglass lenses Yes - No No $0
Routine eye exam Yes - No No $0
Contact lenses Yes - No No $0
Upgrades - - - - Not covered
Eyeglasses (frames and lenses) Yes - No No $0
Other No - - - Not covered
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $0 copay
Emergency - - - - $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fluoride treatment No - - - Not covered
Dental x-ray(s) Yes - No No $0 copay
Cleaning Yes - No No $0 copay
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes Yes $0 copay
Physical therapy and speech and language therapy visit - - Yes Yes $0 copay
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
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - Yes Yes $0
Hearing aids Yes - Yes No $0 copay
Hearing exam - - Yes Yes $0 copay
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Covered
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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