Anthem MediBlue Access (PPO)
H7728 - 004 - 2
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Anthem MediBlue Access (PPO) is a Medicare Advantage (Part C) Plan by Anthem Blue Cross and Blue Shield.
This page features plan details for 2022 Anthem MediBlue Access (PPO) H7728 – 004 – 2 available in Select Counties in Kentucky.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Anthem MediBlue Access (PPO) is offered in the following locations.
Plan Overview
Anthem MediBlue Access (PPO) offers the following coverage and cost-sharing.
| Insurer: | Anthem Blue Cross and Blue Shield |
| Health Plan Deductible: | $500 |
| MOOP: | $5,900.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan's deductible only applies to out-of-network services.
Ready to sign up for Anthem MediBlue Access (PPO) ?
Premium Breakdown
Anthem MediBlue Access (PPO) has a monthly premium of $34.3. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $24.70 | $34.30 | $0.00 | $229.10 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Anthem MediBlue Access (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $34.30 | $26.90 | $19.50 | $12.10 | $4.60 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Anthem MediBlue Access (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | Not covered |
| Endodontics: | Not covered |
| Extractions: | Not covered |
| Non-routine services: | Not covered |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | Not covered |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) |
| Cleaning: | Out-of-Network: 20% coinsurance (limits may apply) |
| Dental x-ray(s): | Not covered |
| Fluoride treatment: | Not covered |
| Oral exam: | In-Network: $0 copay (limits may apply) |
| Oral exam: | Out-of-Network: 20% coinsurance (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $140-215 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 40% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $0-160 copay (authorization required) |
| Diagnostic tests and procedures: | Out-of-Network: 40% coinsurance (authorization required) |
| Lab services: | In-Network: $0-20 copay (authorization required) |
| Lab services: | Out-of-Network: 40% coinsurance (authorization required) |
| Outpatient x-rays: | In-Network: $50-120 copay (authorization required) |
| Outpatient x-rays: | Out-of-Network: 40% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $10 copay per visit |
| Primary: | Out-of-Network: $40 copay per visit |
| Specialist: | In-Network: $40 copay per visit (authorization required) |
| Specialist: | Out-of-Network: $60 copay per visit (authorization required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $35 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $0-40 copay (authorization required) |
| Foot exams and treatment: | Out-of-Network: $60 copay (authorization required) |
| Routine foot care: | In-Network: $0 copay (authorization required) |
| Routine foot care: | Out-of-Network: $60 copay (authorization required) |
Ground ambulance
| In-Network: $265 copay | |
| In-Network: $295 copay | |
| Out-of-Network: $295 copay | |
| Out-of-Network: $265 copay |
Health plan deductible
| $500 annual deductible |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization required) |
| Fitting/evaluation: | Out-of-Network: 20% coinsurance (limits may apply) (authorization required) |
| Hearing aids: | In-Network: $0 copay (limits may apply) (authorization required) |
| Hearing aids: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Hearing exam: | In-Network: $40 copay (authorization required) |
| Hearing exam: | Out-of-Network: $60 copay (authorization required) |
Hospital coverage (inpatient)
| In-Network: $310 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) | |
| Out-of-Network: 35% per stay (authorization required) | |
| Out-of-Network: 40% per stay (authorization required) |
Hospital coverage (outpatient)
| In-Network: $0-290 copay per visit (authorization required) | |
| Out-of-Network: 40% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $6,900 In and Out-of-network $5,900 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay |
| Diabetes supplies: | Out-of-Network: 40% coinsurance per item |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 0-20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 40% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 40% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $235 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 35% per stay (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 40% per stay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $60 copay (authorization required) |
| Outpatient group therapy visit: | In-Network: $40 copay (authorization required) |
| Outpatient group therapy visit: | Out-of-Network: $60 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $60 copay (authorization required) |
| Outpatient individual therapy visit: | In-Network: $40 copay (authorization required) |
| Outpatient individual therapy visit: | Out-of-Network: $60 copay (authorization required) |
Optional supplemental benefits
| Yes |
Preventive care
| In-Network: $0 copay | |
| Out-of-Network: 40% coinsurance |
Rehabilitation services
| Occupational therapy visit: | In-Network: $40 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: $60 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $60 copay (authorization required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) | |
| Out-of-Network: 35% per stay (authorization required) |
Transportation
| Not covered |
Vision
| Contact lenses: | Not covered |
| Eyeglass frames: | Not covered |
| Eyeglass lenses: | Not covered |
| Eyeglasses (frames and lenses): | Not covered |
| Other: | Not covered |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization required) |
| Routine eye exam: | Out-of-Network: $0 copay (limits may apply) (authorization required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $20.00 |
| Preventive dental: | Deductible: | N/A |
Package #2
| Preventive dental: | Monthly Premium: | $29.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $29.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $29.00 |
| Eyewear: | Deductible: | N/A |
Package #3
| Preventive dental: | Monthly Premium: | $58.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $58.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $58.00 |
| Eyewear: | Deductible: | N/A |
Ready to sign up for Anthem MediBlue Access (PPO) ?