Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5854-012-000
Plan Organization Anthem Blue Cross and Blue Shield
Plan Type Local HMO
Plan Name Anthem MediBlue ESRD Care (HMO-POS C-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors Only (some exceptions)
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Chronic or Disabling Condition
Conditions Covered End-stage Renal Disease Requiring Dialysis (any mode of dialysis)
Overall Star Rating 4
Plan Cost Sharing
Premium $16.40
Total Premium (Includes Part B) $151.90
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $16.40
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $16.40
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $4.10
Monthly Part D Premium 50% Assistance $8.20
Monthly Part D Premium 25% Assistance $12.30
Part D Drug Deductible $310.00
Annual Drug Deductible $310.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

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 In-Network No No $0 copay
Endodontics Yes In-Network No No $0 copay
Extractions Yes In-Network No No $0 copay
Non-routine services Yes In-Network No No $0 copay
Periodontics Yes In-Network No No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes In-Network No No $0 copay
Restorative services Yes In-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 20% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes Yes 20% coinsurance
Lab services - Out-of-Network Yes Yes 20% coinsurance
Outpatient x-rays - Out-of-Network Yes Yes 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $0 copay
Specialist - Out-of-Network Yes Yes $0 copay or 20% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $25 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 20% coinsurance
Routine foot care No In-Network Yes Yes $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 20% coinsurance
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 In-Network Yes Yes $0 copay
Hearing aids Yes In-Network Yes No $0 copay
Hearing exam - In-Network Yes Yes 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No Coming soon
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $11,300 In and Out-of-network$7,550 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - In-Network Yes - 0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20% coinsurance
Other Part B drugs - Out-of-Network Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No Coming soon
Outpatient group therapy visit - Out-of-Network Yes Yes 20% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes Yes 20% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes Yes 20% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes Yes 20% coinsurance
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
- Out-of-Network Yes Yes 20% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 20% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes In-Network No No $0 copay
Dental x-ray(s) Yes In-Network No No $0 copay
Fluoride treatment No - - - Not covered
Oral exam Yes In-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes Yes 20% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes Yes 20% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No Not Applicable
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes In-Network No No $0 copay
Eyeglass frames Yes In-Network No No $0 copay
Eyeglass lenses Yes In-Network No No $0 copay
Eyeglasses (frames and lenses) Yes In-Network No No $0 copay
Other No - - - Not covered
Routine eye exam Yes In-Network 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
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

NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.