2020 Anthem MediBlue Dual Plus (HMO D-SNP) - H0544-089-0 in CA Plan Benefits Details (2024)

2020 Medicare Advantage Plan Details Medicare Plan Name:Anthem MediBlue Dual Plus (HMO D-SNP)Location:San Francisco, California Click to see other locationsPlan ID:H0544 - 089 - 0 Click to see other plansMember Services:1-844-469-6831 — This plan information is for research purposes only. —
Click here to see plans for the current plan yearMedicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance Email a copy of the Anthem MediBlue Dual Plus (HMO D-SNP) benefit details — Medicare Plan Features —Monthly Premium:$0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below)Annual Deductible:$0 for people who qualify for both Medicare and Medicaid. Annual Initial Coverage Limit (ICL):$4,020Health Plan Type:Local HMOSpecial Needs Plan (SNP)
Eligibility Requirement:Dual-EligibleAdditional Gap Coverage?Yes, some additional gap coverage.Total Number of Formulary Drugs:3,831 drugsBrowse the Anthem MediBlue Dual Plus (HMO D-SNP) FormularyThis plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5 • Preferred Pharmacy
Cost-Sharing during
initial coverage phase:$0.00$14.00$47.00$95.0025%• Number of Drugs per
Tier:32011376521022700Plan Offers Mail Order?YesMedicare Plan Pharmacy Numbers: BIN: 020115 PCN: IS See BIN/PCNs for all plansNumber of Members enrolled in this plan in San Francisco, California:1,514 membersNumber of Members enrolled in this plan in (H0544 - 089):4,311 members Plan’s Summary Star Rating: 4 out of 5 Stars.• Customer Service Rating: 5 out of 5 Stars.• Member Experience Rating: 3 out of 5 Stars.• Drug Cost Accuracy Rating: 4 out of 5 Stars.— Plan Premium Details —The Monthly Premium is Split as Follows: ❔
Total
PremiumPart C
PremiumPart D Base
PremiumPart D Supplemental
Premium$22.20$0.00$22.20$0.00Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy75%
Subsidy50%
Subsidy25%
SubsidyMonthly Part D Premium with LIS:$0.00$5.50$11.10$16.60Total Monthly Premium with LIS (Parts C & D):$0.00$5.50$11.10$16.60

— Plan Health Benefits — ** Base Plan ** Premium• Health plan premium: $0• Drug plan premium: $22.20• You must continue to pay your Part B premium.• Part B premium reduction: No Deductible• Health plan deductible: $0 • Other health plan deductibles: In-network: No • Drug plan deductible: $435.00 annual deductible Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)• $6,700 In-network Optional supplemental benefits• No Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?• In-network: No Doctor visits• Primary: $0 copay • Specialist: $0 copay (authorization and referral required) Diagnostic procedures/lab services/imaging• Diagnostic tests and procedures: 0% or 20% coinsurance (authorization and referral required) • Lab services: 0% or 20% coinsurance (authorization and referral required) • Diagnostic radiology services (e.g., MRI): 0% or 20% coinsurance (authorization and referral required) • Outpatient x-rays: 0% or 20% coinsurance (authorization and referral required) Emergency care/Urgent care• Emergency: $0 or $90 copay per visit (always covered) • Urgent care: $0 or $65 copay per visit (always covered) Inpatient hospital coverage• In 2020 the amounts for each benefit period are $0 or:
$1,408 deductible for days 1 through 60
$352 copay per day for days 61 through 90 (authorization required) Outpatient hospital coverage• 0% or 20% coinsurance per visit (authorization and referral required) Skilled Nursing Facility• In 2020 the amounts for each benefit period are $0 or:
$0 copay for days 1 through 20
$176.00 copay per day for days 21 through 100 (authorization required) Preventive care• $0 copay Ground ambulance• 0% or 20% coinsurance Rehabilitation services• Occupational therapy visit: 0% or 20% coinsurance (authorization and referral required) • Physical therapy and speech and language therapy visit: 0% or 20% coinsurance (authorization and referral required) Mental health services• Inpatient hospital - psychiatric: In 2020 the amounts for each benefit period are $0 or:
$1,408 deductible for days 1 through 60
$352 copay per day for days 61 through 90 (authorization required) • Outpatient group therapy visit with a psychiatrist: 0% or 20% coinsurance (authorization and referral required) • Outpatient individual therapy visit with a psychiatrist: 0% or 20% coinsurance (authorization and referral required) • Outpatient group therapy visit: 0% or 20% coinsurance (authorization and referral required) • Outpatient individual therapy visit: 0% or 20% coinsurance (authorization and referral required) Opioid treatment program services• In-network: 20% coinsurance (authorization and referral required) Medical equipment/supplies• Durable medical equipment (e.g., wheelchairs, oxygen): $0 copay or 20% coinsurance per item (authorization required) • Prosthetics (e.g., braces, artificial limbs): 0% or 20% coinsurance per item (authorization required) • Diabetes supplies: $0 copay (authorization required) Dialysis• 20% coinsurance Hearing• Hearing exam: 0% or 20% coinsurance (authorization and referral required) • Fitting/evaluation: $0 copay (limits apply, authorization and referral required) • Hearing aids: $0 copay (limits apply, authorization required) Preventive dental• Oral exam: $0 copay (limits apply) • Cleaning: $0 copay (limits apply) • Fluoride treatment: Not covered • Dental x-ray(s): $0 copay (limits apply) Comprehensive dental• Non-routine services: Not covered • Diagnostic services: Not covered • Restorative services: Not covered • Endodontics: Not covered • Periodontics: Not covered • Extractions: Not covered • Prosthodontics, other oral/maxillofacial surgery, other services: Not covered Vision• Routine eye exam: $0 copay (limits apply) • Other: Not covered • Contact lenses: $0 copay (limits apply) • Eyeglasses (frames and lenses): $0 copay (limits apply) • Eyeglass frames: $0 copay (limits apply) • Eyeglass lenses: $0 copay (limits apply) • Upgrades: Not covered Wellness programs (e.g., fitness, nursing hotline)• Covered (authorization required) Transportation• $0 copay (authorization required) Foot care (podiatry services)• Foot exams and treatment: 0% or 20% coinsurance (authorization and referral required) • Routine foot care: $0 copay (authorization and referral required) Medicare Part B drugs• Chemotherapy: 0% or 20% coinsurance (authorization required) • Other Part B drugs: 0% or 20% coinsurance (authorization required) Medically-approved non-opioid pain management services• Chiropractic services: Not covered• Acupuncture: Some coverage• Therapeutic Massage: Not covered• Alternative Therapies: Not covered More benefits• Transportation services: Some coverage• Transportation services for non-emergency care: Plan-approved locations: Not covered• Over-the-counter drug benefits: Some coverage• Meals for short duration: Some coverage• Annual physical exams: Some coverage• Telehealth: Some coverage• WorldWide emergency transportation: Some coverage• WorldWide emergency coverage: Some coverage• WorldWide emergency urgent care: Some coverage• Fitness Benefit: Some coverage• In-Home Support Services: Not covered• Bathroom Safety Devices: Not covered• Health Education: Not covered• In-Home Safety Assessment: Not covered• Personal Emergency Response System (PERS): Some coverage• Medical Nutrition Therapy (MNT): Not covered• Post discharge In-Home Medication Reconciliation: Not covered• Re-admission Prevention: Not covered• Wigs for Hair Loss Related to Chemotherapy: Not covered• Weight Management Programs: Not covered• Adult Day Health Services: Not covered• Nutritional/Dietary Benefit: Not covered• Home-Based Palliative Care: Not covered• Support for Caregivers of Enrollees: Not covered• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered• Enhanced Disease Management: Not covered• Telemonitoring Services: Not covered• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage• Counseling Services: Not covered