Anthem MediBlue Care To You (HMO I-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Anthem Blue Cross and Blue Shield.
This page features plan details for 2023 Anthem MediBlue Care To You (HMO I-SNP) H5854 – 014 – 0 available in Select Counties in CT.
Anthem MediBlue Care To You (HMO I-SNP) is offered in the following locations.
Anthem MediBlue Care To You (HMO I-SNP) offers the following coverage and cost-sharing.
Special Needs Plan Type: | Institutional |
Conditions Covered: |
Insurer: | Anthem Blue Cross and Blue Shield |
Health Plan Deductible: | $0.00 |
MOOP: | $3,650 In-network |
Drugs Covered: | Yes |
Ready to sign up for Anthem MediBlue Care To You (HMO I-SNP) ?
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Anthem MediBlue Care To You (HMO I-SNP) qualifies for a monthly Medicare Give Back Benefit of $25.00.
Premium Reduction: | $25.00 |
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$164.90 | $0.00 | $36.30 | $25.00 | $176.20 |
Anthem MediBlue Care To You (HMO I-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $0.00 |
Initial Coverage Limit: | $4,660.00 |
Catastrophic Coverage Limit: | $7,400.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | Yes |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$36.30 | $43.40 | $34.80 | $26.30 | $17.70 |
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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
2 (Generic) | $7.50 copay | $0.00 copay | ||
3 (Preferred Brand) | $40.00 copay | $40.00 copay | ||
4 (Non-Preferred Drug) | $85.00 copay | $85.00 copay | ||
5 (Specialty Tier) | 33% | 33% | ||
6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | ||||
2 (Generic) | ||||
3 (Preferred Brand) | ||||
4 (Non-Preferred Drug) | ||||
5 (Specialty Tier) | ||||
6 (Select Care Drugs) |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
2 (Generic) | $22.50 copay | $0.00 copay | ||
3 (Preferred Brand) | $120.00 copay | $80.00 copay | ||
4 (Non-Preferred Drug) | $255.00 copay | $170.00 copay | ||
5 (Specialty Tier) | ||||
6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
2 (Generic) | $7.50 copay | $0.00 copay | ||
6 (Select Care Drugs) * | $0.00 copay | $0.00 copay |
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
2 (Generic) | $22.50 copay | $0.00 copay | ||
6 (Select Care Drugs) * | $0.00 copay | $0.00 copay |
Tier | Cost |
---|---|
All other tiers (Generic) | 25% |
All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Drug Type | Cost Share |
---|---|
1 (Preferred Generic) | $0.00 copay |
2 (Generic) | $4.15 copay or 5% (whichever costs more) |
3 (Preferred Brand) | $10.35 copay or 5% (whichever costs more) |
4 (Non-Preferred Drug) | $10.35 copay or 5% (whichever costs more) |
5 (Specialty Tier) | $10.35 copay or 5% (whichever costs more) |
6 (Select Care Drugs) | $0.00 copay |
Anthem MediBlue Care To You (HMO I-SNP) also provides the following benefits.
In-Network: No |
Diagnostic services: | $0 copay (limits may apply) (authorization required) (referral not required) |
Endodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
Extractions: | $0 copay (limits may apply) (authorization required) (referral not required) |
Non-routine services: | $0 copay (limits may apply) (authorization required) (referral not required) |
Periodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization required) (referral not required) |
Restorative services: | $0 copay (limits may apply) (authorization required) (referral not required) |
Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
Fluoride treatment: | Not covered (no limits) |
Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | $75 copay (authorization required) (referral not required) |
Diagnostic tests and procedures: | $0 copay (authorization required) (referral not required) |
Lab services: | $0 copay (authorization required) (referral not required) |
Outpatient x-rays: | $0 copay (authorization required) (referral not required) |
Primary: | $0 copay |
Specialist: | $0 copay (authorization required) (referral not required) |
Emergency: | $75 copay per visit (always covered) |
Urgent care: | $0 copay |
Foot exams and treatment: | $0 copay (authorization required) (referral not required) |
Routine foot care: | $0 copay (no limits) (authorization required) (referral not required) |
$175 copay |
$0.00 |
In-Network: No |
Fitting/evaluation: | $0 copay (limits may apply) (authorization required) (referral not required) |
Hearing aids: | $0 copay (limits may apply) (authorization required) (referral not required) |
Hearing exam: | $0 copay (authorization required) (referral not required) |
$0 copay per stay (authorization required) (referral not required) |
$0 copay (authorization required) (referral not required) |
$3,650 In-network |
Diabetes supplies: | $0 copay (authorization not required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | $0 copay or 20% coinsurance per item (authorization required) |
Chemotherapy: | 20% coinsurance (authorization required) |
Other Part B drugs: | 0-20% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | $0 copay per stay (authorization required) (referral not required) |
Outpatient group therapy visit: | $0 copay (authorization required) (referral not required) |
Outpatient group therapy visit with a psychiatrist: | $0 copay (authorization required) (referral not required) |
Outpatient individual therapy visit: | $0 copay (authorization required) (referral not required) |
Outpatient individual therapy visit with a psychiatrist: | $0 copay (authorization required) (referral not required) |
No |
$0 copay (authorization not required) (referral not required) |
Occupational therapy visit: | $0 copay (authorization required) (referral not required) |
Physical therapy and speech and language therapy visit: | $0 copay (authorization required) (referral not required) |
$0 copay per stay (authorization required) (referral not required) |
$0 copay (limits may apply) (authorization not required) (referral not required) |
Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
Other: | Not covered (no limits) |
Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Upgrades: | Not covered |
Covered (authorization not required) (referral not required) |
Ready to sign up for Anthem MediBlue Care To You (HMO I-SNP) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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