Anthem MediBlue ESRD Care (HMO-POS C-SNP)

3 out of 5 stars* for plan year 2023
$11.60 Monthly Premium

Anthem MediBlue ESRD Care (HMO-POS C-SNP) is a HMO-POS C-SNP Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield

Plan ID: H5854-012-000

$11.60 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$11.60
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$310.00
Out-of-pocket maximum$8,300.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:
$0.00 copay
Specialty doctor visitIn-Network:
$0.00 copay - 20% coinsurance
Inpatient hospital careIn-Network:
Medicare-defined Cost Share
Urgent careUrgent Care: $25.00 copay
Emergency room visitEmergency Care: $90.00 copay
Ambulance transportationGround Ambulance: 20% coinsurance Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem MediBlue ESRD Care (HMO-POS C-SNP) covers a range of additional benefits. Learn more about Anthem MediBlue ESRD Care (HMO-POS C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
Out-of-Network:
Medicare Covered Chiropractic Services: 20% coinsurance
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:
Diabetic Supplies: $0.00 copay
Durable medical equipment (DME)In-Network:
20% coinsurance
Diagnostic tests, lab and radiology services, and X-raysIn-Network:
Lab Services: 20% coinsurance
X-Rays: 20% coinsurance
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: 20% coinsurance
Diagnostic Radiological Services: 20% coinsurance
Home health care
Out-of-Network:
$0.00 copay
Mental health inpatient careIn-Network:
Medicare-defined Cost Share
Mental health outpatient careIn-Network:
Individual and Group Sessions: 20% coinsurance
Outpatient services/surgeryIn-Network:
Outpatient Hospital - Surgery: 20% coinsurance
Observation Services: 20% coinsurance
Ambulatory Surgical Center: 20% coinsurance
Outpatient substance abuse care
Out-of-Network:
20% coinsurance
Over-the-counter itemsThis plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $100 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: 20% coinsurance
Skilled Nursing Facility (SNF) careIn-Network:
Medicare-defined Cost Share

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: 20% coinsurance
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 benefitsIn-Network:
Medicare Covered Eye Exam: 20% coinsurance
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: 20% coinsurance
Routine Eye Wear: $0.00 copay
This plan covers up to $125.00 for eyeglasses or contact lenses every year.

Hearing Benefits

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

Coverage Details
Hearing benefitsIn-Network:
Medicare Covered Hearing Exam: 20% coinsurance
Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount.
This plan covers 1 routine hearing exam(s) and hearing aid fitting/evaluation(s) every year. $2,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year.

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 programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services

Prescription Drug Costs and Coverage

The Anthem MediBlue ESRD Care (HMO-POS C-SNP) offers prescription drug coverage, with an annual drug deductible of $310.00 (excludes Tiers 1 and 6)

Coverage
Cost
Coverage & Cost
Annual drug deductible$310.00 (excludes Tiers 1 and 6)
Tier 1
  • Preferred retail $3.00
  • Standard retail $8.00
  • Standard mail order $0.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
  • Annual drug deductible$310.00 (excludes Tiers 1 and 6)
    Tier 1
  • Preferred retail $6.00
  • Standard retail $16.00
  • Standard mail order $0.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
  • Annual drug deductible$310.00 (excludes Tiers 1 and 6)
    Tier 1
  • Preferred retail $9.00
  • Standard retail $24.00
  • 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 Tolland
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