Anthem MediBlue Access (PPO) - 2021

Anthem MediBlue Access (PPO) - Anthem Blue Cross and Blue Shield - Local PPO

Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H7728-005-000
Plan Organization Anthem Blue Cross and Blue Shield
Plan Type Local PPO
Plan Name Anthem MediBlue Access (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
Plan Cost Sharing
Premium $59.00
Total Premium (Includes Part B) $194.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $59.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $59.00
Monthly Part D Premium Full Assistance $29.20
Monthly Part D Premium 75% Assistance $36.60
Monthly Part D Premium 50% Assistance $44.10
Monthly Part D Premium 25% Assistance $51.50
Part D Drug Deductible $95.00
Annual Drug Deductible $95.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5900.00
Gap Coverage Yes

Medicare Advantage Plan Health Benefits


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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes Out-of-Network No No $0 copay
Endodontics Yes Out-of-Network No No $0 copay
Extractions Yes Out-of-Network No No $0 copay
Non-routine services Yes Out-of-Network No No $0 copay
Periodontics Yes Out-of-Network No No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network No No $0 copay
Restorative services Yes Out-of-Network No No $0 copay
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% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes Yes 40% coinsurance
Lab services - Out-of-Network Yes Yes 40% coinsurance
Outpatient x-rays - Out-of-Network Yes Yes 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $35 copay per visit
Specialist - Out-of-Network Yes Yes $60 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $30 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes Yes $60 copay
Routine foot care No Out-of-Network Yes Yes $60 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $295 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $500 annual deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes Out-of-Network Yes Yes 20% coinsurance
Hearing aids Yes Out-of-Network Yes No $0 copay
Hearing exam - Out-of-Network Yes Yes $60 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 25% per stay
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$5,900 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 35% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 35% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 35% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 30% coinsurance
Other Part B drugs - Out-of-Network Yes - 30% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 25% per stay
Outpatient group therapy visit - Out-of-Network Yes Yes $60 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes Yes $60 copay
Outpatient individual therapy visit - Out-of-Network Yes Yes $60 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes Yes $60 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes Yes 40% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 40% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No 20% coinsurance
Dental x-ray(s) Yes Out-of-Network No No 20% coinsurance
Fluoride treatment No - - - Not covered
Oral exam Yes Out-of-Network No No 20% coinsurance
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes Yes $60 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes Yes $60 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 25% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network No No $0 copay
Eyeglass frames Yes Out-of-Network No No $0 copay
Eyeglass lenses Yes Out-of-Network No No $0 copay
Eyeglasses (frames and lenses) Yes Out-of-Network No No $0 copay
Other 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

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Preventive dental Monthly Premium $19.00
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $27.00
Eyewear Monthly Premium $27.00
Preventive dental Monthly Premium $27.00
Package #3
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $53.00
Eyewear Monthly Premium $53.00
Preventive dental Monthly Premium $53.00
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Barrow County, Georgia, Bartow County, Georgia, Bibb County, Georgia, Bryan County, Georgia, Bulloch County, Georgia, Burke County, Georgia, Butts County, Georgia, Catoosa County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Cherokee County, Georgia, Clayton County, Georgia, Cobb County, Georgia, Coffee County, Georgia, Columbia County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dawson County, Georgia, Dekalb County, Georgia, Dodge County, Georgia, Douglas County, Georgia, Effingham County, Georgia, Evans County, Georgia, Fayette County, Georgia, Forsyth County, Georgia, Fulton County, Georgia, Gilmer County, Georgia, Glascock County, Georgia, Greene County, Georgia, Gwinnett County, Georgia, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Jasper County, Georgia, Jefferson County, Georgia, Johnson County, Georgia, Jones County, Georgia, Lamar County, Georgia, Laurens County, Georgia, Liberty County, Georgia, Macon County, Georgia, Marion County, Georgia, Mcduffie County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Monroe County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pierce County, Georgia, Pike County, Georgia, Polk County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Spalding County, Georgia, Talbot County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Tift County, Georgia, Toombs County, Georgia, Troup County, Georgia, Twiggs County, Georgia, Walton County, Georgia, Warren County, Georgia, Washington County, Georgia, White County, Georgia

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