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Anthem MediBlue ESRD Care (PPO C-SNP)

H8552 - 028 - 0
3 out of 5 stars (3 / 5)

Anthem MediBlue ESRD Care (PPO C-SNP) is a Medicare Advantage Special Needs Plan by Anthem Blue Cross Life and Health Insurance Co..

This page features plan details for 2023 Anthem MediBlue ESRD Care (PPO C-SNP) H8552 – 028 – 0 available in Select Counties in California.

IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:

2025 Anthem Kidney Care (PPO C-SNP) H8552 - 028 - 0

Locations

Anthem MediBlue ESRD Care (PPO C-SNP) is offered in the following locations.

California
Fresno County, California
Kern County, California

Click to see more locations

Plan Overview

Anthem MediBlue ESRD Care (PPO C-SNP) offers the following coverage and cost-sharing.

Special Needs Plan Type:Chronic or Disabling Condition
Conditions Covered:
  • End-stage Renal Disease Requiring Dialysis (any mode of dialysis)
    • Insurer:Anthem Blue Cross Life and Health Insurance Co.
    Health Plan Deductible:$1,600 per year for some in-network and out-of-network services.
    MOOP:$12,450 In and Out-of-network
    $8,300 In-network
    Drugs Covered:Yes
    Please Note:
    • This plan does not charge an annual deductible for all drugs. The $130.00 annual deductible only applies to drugs on certain tiers.

    Ready to sign up for Anthem MediBlue ESRD Care (PPO C-SNP) ?

    Get help from a licensed insurance agent.

    Call 1-877-354-4611 / TTY 711.

    M-F: 8:00 am – 10:00 pm EST

    Sat-Sun: 8:00 am – 9:00 pm EST

    Premium Breakdown

    Anthem MediBlue ESRD Care (PPO C-SNP) has a monthly premium of $29.30. 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
    $164.90 $0.00 $29.30 $0.00 $
    Please Note:
    • 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 ESRD Care (PPO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

    Drug Deductible: $130.00
    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 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
    $29.30 $43.40 $34.80 $26.30 $17.70

    Initial Coverage Phase

    After you pay your $130.00 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.

    Gap Coverage Phase

    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 $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

    Drug TypeCost Share
    Generic drugs$4.15 copay or 5% (whichever costs more)
    Brand-name drugs$10.35 copay or 5% (whichever costs more)

    Additional Benefits

    Anthem MediBlue ESRD Care (PPO C-SNP) 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:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Diagnostic services:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Endodontics:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Endodontics:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Extractions:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Extractions:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Non-routine services:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Non-routine services:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Periodontics:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Periodontics:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Prosthodontics, other oral/maxillofacial surgery, other services:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Prosthodontics, other oral/maxillofacial surgery, other services:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Restorative services:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
    Restorative services:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)

    Dental (preventive)

    Cleaning:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Cleaning:Out-of-Network: 20% coinsurance (limits may apply) (authorization not required) (referral not required)
    Dental x-ray(s):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Dental x-ray(s):Out-of-Network: 20% coinsurance (limits may apply) (authorization not required) (referral not required)
    Fluoride treatment: Not covered (no limits)
    Oral exam:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Oral exam:Out-of-Network: 20% coinsurance (limits may apply) (authorization not required) (referral not required)

    Diagnostic procedures/lab services/imaging

    Diagnostic radiology services (e.g., MRI):In-Network: 20% coinsurance (authorization required) (referral not required)
    Diagnostic radiology services (e.g., MRI):Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Diagnostic tests and procedures:In-Network: 20% coinsurance (authorization required) (referral not required)
    Diagnostic tests and procedures:Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Lab services:In-Network: 20% coinsurance (authorization required) (referral not required)
    Lab services:Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Outpatient x-rays:In-Network: 20% coinsurance (authorization required) (referral not required)
    Outpatient x-rays:Out-of-Network: 20% coinsurance (authorization required) (referral not required)

    Doctor visits

    Primary:In-Network: $0 copay
    Primary:Out-of-Network: $0 copay
    Specialist:In-Network: $0 copay or 20% coinsurance per visit (authorization required) (referral not required)
    Specialist:Out-of-Network: $0 copay or 20% coinsurance per visit (authorization required) (referral not required)

    Emergency care/Urgent care

    Emergency: $90 copay per visit (always covered)
    Urgent care: $25 copay per visit (always covered)

    Foot care (podiatry services)

    Foot exams and treatment:In-Network: $0 copay or 20% coinsurance (authorization required) (referral not required)
    Foot exams and treatment:Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Routine foot care:In-Network: $0 copay (no limits) (authorization required) (referral not required)
    Routine foot care:Out-of-Network: 20% coinsurance (no limits) (authorization required) (referral not required)

    Ground ambulance

    In-Network: 20% coinsurance
    Out-of-Network: 20% coinsurance

    Health plan deductible

    $1,600 per year for some in-network and out-of-network services.

    Health plan deductibles (other)

    In-Network: No

    Hearing

    Fitting/evaluation: Not covered (no limits)
    Hearing aids – inner ear: Not covered (no limits)
    Hearing aids – outer ear: Not covered (no limits)
    Hearing aids – over the ear: Not covered (no limits)
    Hearing exam:In-Network: 20% coinsurance (authorization required) (referral not required)
    Hearing exam:Out-of-Network: 20% coinsurance (authorization required) (referral not required)

    Hospital coverage (inpatient)

    In-Network: In 2023 the amounts for each benefit period are:
    $1,600 deductible for days 1 through 60
    $400 copay per day for days 61 through 90 (authorization required) (referral not required)
    Out-of-Network: In 2023 the amounts for each benefit period are:
    $1,600 deductible for days 1 through 60
    $400 copay per day for days 61 through 90 (authorization required) (referral not required)

    Hospital coverage (outpatient)

    In-Network: 20% coinsurance per visit (authorization required) (referral not required)
    Out-of-Network: 20% coinsurance per visit (authorization required) (referral not required)

    Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    $12,450 In and Out-of-network
    $8,300 In-network

    Medical equipment/supplies

    Diabetes supplies:In-Network: $0 copay (authorization not required)
    Diabetes supplies:Out-of-Network: 20% coinsurance per item (authorization not required)
    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: 20% 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: 20% 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: In 2023 the amounts for each benefit period are:
    $1,600 deductible for days 1 through 60
    $400 copay per day for days 61 through 90 (authorization required) (referral not required)
    Inpatient hospital – psychiatric:Out-of-Network: In 2023 the amounts for each benefit period are:
    $1,600 deductible for days 1 through 60
    $400 copay per day for days 61 through 90 (authorization required) (referral not required)
    Outpatient group therapy visit:In-Network: $0 copay (authorization required) (referral not required)
    Outpatient group therapy visit:Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Outpatient group therapy visit with a psychiatrist:In-Network: 20% coinsurance (authorization required) (referral not required)
    Outpatient group therapy visit with a psychiatrist:Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Outpatient individual therapy visit:In-Network: $0 copay (authorization required) (referral not required)
    Outpatient individual therapy visit:Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Outpatient individual therapy visit with a psychiatrist:In-Network: 20% coinsurance (authorization required) (referral not required)
    Outpatient individual therapy visit with a psychiatrist:Out-of-Network: 20% coinsurance (authorization required) (referral not required)

    Optional supplemental benefits

    No

    Preventive care

    In-Network: $0 copay (authorization not required) (referral not required)
    Out-of-Network: 20% coinsurance (authorization not required) (referral not required)

    Rehabilitation services

    Occupational therapy visit:In-Network: 20% coinsurance (authorization required) (referral not required)
    Occupational therapy visit:Out-of-Network: 20% coinsurance (authorization required) (referral not required)
    Physical therapy and speech and language therapy visit:In-Network: 20% coinsurance (authorization required) (referral not required)
    Physical therapy and speech and language therapy visit:Out-of-Network: 20% coinsurance (authorization required) (referral not required)

    Skilled Nursing Facility

    In-Network: In 2023 the amounts for each benefit period are:
    $0 copay for days 1 through 20
    $200 copay per day for days 21 through 100 (authorization required) (referral not required)
    Out-of-Network: In 2023 the amounts for each benefit period are:
    $0 copay for days 1 through 20
    $200 copay per day for days 21 through 100 (authorization required) (referral not required)

    Transportation

    In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)

    Vision

    Contact lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Contact lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglass frames:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglass frames:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglass lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglass lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglasses (frames and lenses):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Eyeglasses (frames and lenses):Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Other: Not covered (no limits)
    Routine eye exam:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Routine eye exam:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
    Upgrades: Not covered

    Wellness programs (e.g., fitness, nursing hotline)

    Covered (authorization not required) (referral not required)

    Ready to sign up for Anthem MediBlue ESRD Care (PPO C-SNP) ?

    Get help from a licensed insurance agent.

    Call 1-877-354-4611 / TTY 711.

    M-F: 8:00 am – 10:00 pm EST

    Sat-Sun: 8:00 am – 9:00 pm EST

    Table of Contents

    Need more information on Anthem MediBlue ESRD Care (PPO C-SNP)? See 2025 Anthem MediBlue ESRD Care (PPO C-SNP) at MedicareAdvantageRX.com.

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