Anthem MediBlue Access Select (PPO)

3 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

Anthem MediBlue Access Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield

Plan ID: H2836-005-000

$0.00 Monthly Premium

Connecticut Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Connecticut Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$95.00
Out-of-pocket maximum$7,550.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visit
Out-of-Network:
$35.00 copay
Specialty doctor visit
Out-of-Network:
$60.00 copay
Inpatient hospital care
Out-of-Network:
40% coinsurance per stay
Urgent careUrgent Care: $30.00 copay
Emergency room visitEmergency Care: $90.00 copay
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance transportationGround Ambulance: $295.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem MediBlue Access Select (PPO) covers a range of additional benefits. Learn more about Anthem MediBlue Access Select (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:
Medicare Covered Chiropractic Services: $20.00 copay
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:
35% coinsurance
Durable medical equipment (DME)
Out-of-Network:
40% coinsurance
Diagnostic tests, lab and radiology services, and X-raysIn-Network:
Lab Services: $0.00 - $15.00 copay
X-Rays: $15.00 - $30.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 - $140.00 copay
Diagnostic Radiological Services: $130.00 - $150.00 copay
Home health careIn-Network:
$0.00 copay
Mental health inpatient careIn-Network:
Days 1-5: $250.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Mental health outpatient care
Out-of-Network:
40% coinsurance
Outpatient services/surgery
Out-of-Network:
Outpatient Hospital - Surgery: 40% coinsurance
Observation Services: 40% coinsurance
Ambulatory Surgical Center: 40% coinsurance
Outpatient substance abuse careIn-Network:
Individual and Group Sessions: $40.00 copay
Over-the-counter itemsThis plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $35 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.
Podiatry services
Out-of-Network:
Medicare Covered Podiatry Services: $60.00 copay
Routine Foot Care: $60.00 copay
Skilled Nursing Facility (SNF) careIn-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-Network:
Preventive Dental Services: $0.00 copay
This plan covers: 2 oral exam(s), 2 cleaning(s), 1 dental X-ray(s) every year.

Medicare Covered Dental: $0.00 copay
Comprehensive Dental Services: $0.00 copay
This plan covers up to a $750.00 allowance for covered comprehensive dental services every year.

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefits
Out-of-Network:
Medicare Covered Eye Exam: $60.00 copay
Routine Eye Exam: $0.00 copay
Medicare Covered Eye Wear: $0.00 copay
Routine Eye Wear: $0.00 copay

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefits
Out-of-Network:
Medicare Covered Hearing Exam: $60.00 copay
Routine Hearing Exam: 20% coinsurance for routine hearing exam(s).

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programs
Out-of-Network:
40% coinsurance

Prescription Drug Costs and Coverage

The Anthem MediBlue Access Select (PPO) offers prescription drug coverage, with an annual drug deductible of $95.00 (excludes Tiers 1, 2 and 6)

Coverage
Cost
Coverage & Cost
Annual drug deductible$95.00 (excludes Tiers 1, 2 and 6)
Tier 1
  • Preferred retail $4.00
  • Standard retail $9.00
  • Standard mail order $0.00
  • Tier 2
  • Preferred retail $13.00
  • Standard retail $18.00
  • Standard mail order $0.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
  • Annual drug deductible$95.00 (excludes Tiers 1, 2 and 6)
    Tier 1
  • Preferred retail $8.00
  • Standard retail $18.00
  • Standard mail order $0.00
  • Tier 2
  • Preferred retail $26.00
  • Standard retail $36.00
  • Standard mail order $0.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
  • Annual drug deductible$95.00 (excludes Tiers 1, 2 and 6)
    Tier 1
  • Preferred retail $12.00
  • Standard retail $27.00
  • Standard mail order $0.00
  • Tier 2
  • Preferred retail $39.00
  • Standard retail $54.00
  • Standard mail order $0.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
  • When reviewing Connecticut Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Connecticut that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Connecticut Counties Served

    Fairfield Hartford Litchfield Middlesex New Haven New London Tolland Windham
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