Plan Basics
| Contract Year |
2021 |
| 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 |
Plan Cost Sharing
| Premium |
$0.00 |
| Total Premium (Includes Part B) |
$135.50 |
| Monthly Part C Premium |
$0.00 |
| Monthly Part D Basic Premium |
$29.80 |
| Monthly Part D Supplemental Premium |
$0.00 |
| Monthly Part D Total Premium |
$29.80 |
| Monthly Part D Premium Full Assistance |
$0.00 |
| Monthly Part D Premium 75% Assistance |
$7.40 |
| Monthly Part D Premium 50% Assistance |
$14.90 |
| Monthly Part D Premium 25% Assistance |
$22.30 |
| Part D Drug Deductible |
$445.00 |
| Annual Drug Deductible |
$445.00 |
| Tiers Excluded From Deductible |
1 |
| 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 |
$0 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 |
- |
- |
- |
- |
$0 copay |
| 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 |
Yes |
- |
Yes |
Yes |
$0 copay |
Ground Ambulance
| Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$0 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 |
No |
$0 copay |
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
| Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$7,550 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 copay |
| Prosthetics (e.g., braces, artificial limbs) |
- |
- |
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 |
| Inpatient hospital - psychiatric |
- |
- |
Yes |
No |
$0 copay |
| 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 |
|
- |
- |
No |
No |
$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 |
No |
$0 copay |
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 |
- |
No |
No |
$0 copay |
| Eyeglass frames |
Yes |
- |
No |
No |
$0 copay |
| Eyeglass lenses |
Yes |
- |
No |
No |
$0 copay |
| Eyeglasses (frames and lenses) |
Yes |
- |
No |
No |
$0 copay |
| Other |
No |
- |
- |
- |
Not covered |
| Routine eye exam |
Yes |
- |
No |
No |
$0 copay |
| Upgrades |
- |
- |
- |
- |
Not covered |
Wellness Programs (e.g., Fitness, Nursing Hotline)
| Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
Yes |
No |
Covered |
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,
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,
Dekalb County, Georgia,
Dodge County, Georgia,
Douglas County, Georgia,
Effingham County, Georgia,
Fayette County, Georgia,
Forsyth County, Georgia,
Fulton County, Georgia,
Gilmer County, Georgia,
Glascock County, Georgia,
Greene County, Georgia,
Gwinnett County, Georgia,
Harris County, Georgia,
Heard County, Georgia,
Henry County, Georgia,
Houston County, Georgia,
Jasper County, Georgia,
Jefferson County, Georgia,
Jones County, Georgia,
Lamar County, Georgia,
Laurens County, Georgia,
Liberty County, Georgia,
Macon County, Georgia,
Marion County, Georgia,
Mcduffie County, Georgia,
Meriwether County, Georgia,
Monroe County, Georgia,
Muscogee County, Georgia,
Newton County, Georgia,
Paulding County, Georgia,
Peach County, Georgia,
Pickens County, Georgia,
Pike County, Georgia,
Richmond County, Georgia,
Rockdale County, Georgia,
Spalding County, Georgia,
Talbot County, Georgia,
Taylor County, Georgia,
Tift County, Georgia,
Toombs County, Georgia,
Troup County, Georgia,
Twiggs County, Georgia,
Walton County, Georgia,
Warren County, Georgia,
White County, Georgia
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