Anthem MediBlue Care To You (HMO I-SNP) H5854-014-000 is a 2021 Medicare Advantage Institutional Special Needs Plan provided by Anthem Blue Cross and Blue Shield.

A Special Needs Plan (SNP) is a type of Medicare Advantage Plan designed for Medicare beneficiaries with specific conditions or characteristics.

Institutional Special Needs Plans are for beneficiaries who live in an institution, such as a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility. If you don't meet this criteria, consider other plan choices in your county.

Special Needs plans provide both health coverage and drug coverage, and each coverage type has different costs to consider.

This plan has a monthly premium of $7.40, which covers both the health and drug portions of the plan.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $0.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5854-014-000
Plan Organization Anthem Blue Cross and Blue Shield
Plan Type Local HMO
Plan Name Anthem MediBlue Care To You (HMO I-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 Institutional
Overall Star Rating 4
Plan Cost Sharing
Premium $7.40
Total Premium (Includes Part B) $117.90
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $7.40
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $7.40
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $1.80
Monthly Part D Premium 50% Assistance $3.70
Monthly Part D Premium 25% Assistance $5.50
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Gap Coverage Y

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 - No No $0 copay
Endodontics Yes - No No $0 copay
Extractions Yes - No No $0 copay
Non-routine services Yes - No No $0 copay
Periodontics Yes - No No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes - No No $0 copay
Restorative services Yes - No No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes Yes $75 copay
Diagnostic tests and procedures - - Yes Yes $0 copay
Lab services - - Yes Yes $0 copay
Outpatient x-rays - - Yes Yes $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes Yes $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $75 copay per visit (always covered)
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes Yes $0 copay
Routine foot care No - Yes Yes $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $175 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - Yes Yes $0 copay
Hearing aids Yes - Yes No $0 copay
Hearing exam - - Yes Yes $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,400 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - $0 copay or 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20% coinsurance
Other Part B drugs - - Yes - 0-20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes Yes $0 copay per stay
Outpatient group therapy visit - - Yes Yes $0 copay
Outpatient group therapy visit with a psychiatrist - - Yes Yes $0 copay
Outpatient individual therapy visit - - Yes Yes $0 copay
Outpatient individual therapy visit with a psychiatrist - - Yes Yes $0 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
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
- - Yes Yes $0 copay
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0 copay
Fluoride treatment No - - - Not covered
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
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - Yes Yes $0 copay
Eyeglass frames Yes - Yes Yes $0 copay
Eyeglass lenses Yes - Yes Yes $0 copay
Eyeglasses (frames and lenses) Yes - Yes Yes $0 copay
Other No - - - Not covered
Routine eye exam Yes - Yes Yes $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
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

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