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This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Anthem MediBlue Plus (HMO) in Penobscot, Maine

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Anthem MediBlue Plus (HMO) (H8432 - 004) in Penobscot, Maine .

This plan is administered by ANTHEM HEALTH PLANS OF MAINE, INC..  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Anthem MediBlue Plus (HMO) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The Anthem MediBlue Plus (HMO) has a monthly premium of $50.00. That is $600.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $50.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership
The Anthem MediBlue Plus (HMO) (H8432 - 004) currently has 220 members. There are 220 members enrolled in this plan in Penobscot, Maine, and 220 members in Maine.

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2016 is $360. This plan (Anthem MediBlue Plus (HMO)) has no deductible.

The following information is about the Anthem MediBlue Plus (HMO) formulary (or drug list). There are 3266 drugs on the Anthem MediBlue Plus (HMO) formulary. Click here to browse the Anthem MediBlue Plus (HMO) Formulary.
 
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Anthem MediBlue Plus (HMO)’s formulary is divided into 6 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Preferred Generic) contains 188 drugs and has a co-payment of $5.00.
  • Tier 2 (Generic) contains 467 drugs and has a co-payment of $15.00.
  • Tier 3 (Preferred Brand) contains 701 drugs and has a co-payment of $42.00.
  • Tier 4 (Non-Preferred Brand) contains 1,444 drugs and has a co-payment of $95.00.
  • Tier 5 (Specialty Tier) contains 589 drugs and has a co-insurance of 33% of the drug cost.
  • Tier 6 (Select Care Drugs) contains drugs and has a co-payment of $0.00.
Click here to browse the Anthem MediBlue Plus (HMO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 42% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 55% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (Anthem MediBlue Plus (HMO)) offers Coverage in the gap, however Medicare has not specified the details of the gap coverage.

The Anthem MediBlue Plus (HMO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **
Monthly premium, deductible, and limits on how much you pay for covered services
$50 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $6 400 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
No. There are no limits on how much our plan will pay.
** Doctor and Hospital Choice **
Acupuncture
Not covered
** Extra Benefits **
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs1:  20% of the cost
Other Part B drugs1:  20% of the cost
You pay the following until your total yearly drug costs reach $3 150. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$10 copay$20 copay$30 copay
Tier 2 (Generic)$20 copay$40 copay$60 copay
Tier 3 (Preferred Brand)$47 copay$94 copay$141 copay
Tier 4 (Non-Preferred Brand)$100 copay$200 copay$300 copay
Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
Tier 6 (Select Care Drugs)$0$0$0
Preferred Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$5 copay$10 copay$15 copay
Tier 2 (Generic)$15 copay$30 copay$45 copay
Tier 3 (Preferred Brand)$42 copay$84 copay$126 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
Tier 6 (Select Care Drugs)$0$0$0
Standard Mail Order Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$5 copay$15 copay$15 copay
Tier 2 (Generic)$15 copay$45 copay$45 copay
Tier 3 (Preferred Brand)$42 copay$126 copay$126 copay
Tier 4 (Non-Preferred Brand)$95 copay$285 copay$285 copay
Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
Tier 6 (Select Care Drugs)$0$0$0
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 150.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Standard Retail Cost-Sharing
TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
Tier 6 (Select Care Drugs)All$0$0$0
Preferred Retail Cost-Sharing
TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
Tier 6 (Select Care Drugs)All$0$0$0
Standard Mail Order Cost-Sharing
TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
Tier 6 (Select Care Drugs)All$0$0$0
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
  • 5% of the cost or
  • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$50 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $6 400 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
No. There are no limits on how much our plan will pay.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
$300 copay or 20% of the cost depending on the service
Chiropractic care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  $20 copay
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  You pay nothing
Preventive dental services:
  • Cleaning (for up to 1 every year):  You pay nothing
  • Oral exam (for up to 1 every year):  You pay nothing
    • Diabetes supplies and services
    Diabetes monitoring supplies:  You pay nothing
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  You pay nothing
    Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
    Diagnostic radiology services (such as MRIs CT scans):  20% of the cost
    Diagnostic tests and procedures:  $0-90 copay depending on the service
    Lab services:  $30 copay
    Outpatient x-rays:  20% of the cost
    Therapeutic radiology services (such as radiation treatment for cancer):  20% of the cost
    Doctor's office visits
    Primary care physician visit:  $5 copay
    Specialist visit:  $30 copay
    Durable medical equipment (wheelchairs, oxygen, etc.)
    20% of the cost
    Emergency care
    $75 copay
    Foot care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $30 copay
    Hearing services
    Exam to diagnose and treat hearing and balance issues:  $30 copay
    Home health care
    You pay nothing
    Mental health care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • $250 copay per day for days 1 through 4
    • You pay nothing per day for days 5 through 90
      • Outpatient group therapy visit:  $40 copay
      Outpatient individual therapy visit:  $40 copay
      Outpatient rehabilitation
      Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  $20 copay
      Occupational therapy visit:  $40 copay
      Physical therapy and speech and language therapy visit:  $40 copay
      Outpatient substance abuse
      Group therapy visit:  $40 copay
      Individual therapy visit:  $40 copay
      Outpatient surgery
      Ambulatory surgical center:  15% of the cost
      Outpatient hospital:  20% of the cost
      Over-the-counter items
      Not Covered
      Prosthetic devices (braces, artificial limbs, etc.)
      Prosthetic devices:  20% of the cost
      Related medical supplies:  20% of the cost
      Renal dialysis
      20% of the cost
      Transportation
      Not covered
      Urgently needed services
      $55 copay
      Vision services
      Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  You pay nothing
      Routine eye exam (for up to 1 every year):  You pay nothing
      Eyeglasses or contact lenses after cataract surgery:  $30 copay
      ** Hospice **
      Hospice
      You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
      ** Preventive Care **
      Preventive care
      You pay nothing
      Our plan covers many preventive services including:
      • Abdominal aortic aneurysm screening
      • Alcohol misuse counseling
      • Bone mass measurement
      • Breast cancer screening (mammogram)
      • Cardiovascular disease (behavioral therapy)
      • Cardiovascular screenings
      • Cervical and vaginal cancer screening
      • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
      • Depression screening
      • Diabetes screenings
      • HIV screening
      • Medical nutrition therapy services
      • Obesity screening and counseling
      • Prostate cancer screenings (PSA)
      • Sexually transmitted infections screening and counseling
      • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
      • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
      • "Welcome to Medicare" preventive visit (one-time)
      • Yearly "Wellness" visit
      Any additional preventive services approved by Medicare during the contract year will be covered.
      ** Inpatient Care **
      Inpatient hospital care
      The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
      Our plan covers 90 days for an inpatient hospital stay.
      Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
      • $335 copay per day for days 1 through 5
      • You pay nothing per day for days 6 through 90
        • Inpatient mental health care
        For inpatient mental health care see the "Mental Health Care" section.
        Skilled Nursing Facility (SNF)
        Our plan covers up to 100 days in a SNF.
        • You pay nothing per day for days 1 through 20
        • $155 copay per day for days 21 through 100
          • Outpatient prescription drugs
          For Part B drugs such as chemotherapy drugs1:  20% of the cost
          Other Part B drugs1:  20% of the cost
          You pay the following until your total yearly drug costs reach $3 150. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
          You may get your drugs at network retail pharmacies and mail order pharmacies.
          Standard Retail Cost-Sharing
          TierOne-month supplyTwo-month supplyThree-month supply
          Tier 1 (Preferred Generic)$10 copay$20 copay$30 copay
          Tier 2 (Generic)$20 copay$40 copay$60 copay
          Tier 3 (Preferred Brand)$47 copay$94 copay$141 copay
          Tier 4 (Non-Preferred Brand)$100 copay$200 copay$300 copay
          Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
          Tier 6 (Select Care Drugs)$0$0$0
          Preferred Retail Cost-Sharing
          TierOne-month supplyTwo-month supplyThree-month supply
          Tier 1 (Preferred Generic)$5 copay$10 copay$15 copay
          Tier 2 (Generic)$15 copay$30 copay$45 copay
          Tier 3 (Preferred Brand)$42 copay$84 copay$126 copay
          Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
          Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
          Tier 6 (Select Care Drugs)$0$0$0
          Standard Mail Order Cost-Sharing
          TierOne-month supplyTwo-month supplyThree-month supply
          Tier 1 (Preferred Generic)$5 copay$15 copay$15 copay
          Tier 2 (Generic)$15 copay$45 copay$45 copay
          Tier 3 (Preferred Brand)$42 copay$126 copay$126 copay
          Tier 4 (Non-Preferred Brand)$95 copay$285 copay$285 copay
          Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
          Tier 6 (Select Care Drugs)$0$0$0
          If you reside in a long-term care facility you pay the same as at a retail pharmacy.
          You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
          Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 150.

          After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

          Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
          Standard Retail Cost-Sharing
          TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
          Tier 6 (Select Care Drugs)All$0$0$0
          Preferred Retail Cost-Sharing
          TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
          Tier 6 (Select Care Drugs)All$0$0$0
          Standard Mail Order Cost-Sharing
          TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
          Tier 6 (Select Care Drugs)All$0$0$0
          After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
          • 5% of the cost or
          • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
          ** Outpatient Care **
          Diabetes supplies and services
          Diabetes monitoring supplies:  You pay nothing
          Diabetes self-management training:  You pay nothing
          Therapeutic shoes or inserts:  You pay nothing
          Foot care (podiatry services)
          Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $30 copay
          Hearing services
          Exam to diagnose and treat hearing and balance issues:  $30 copay
          ** Outpatient Medical Services and Supplies **
          Outpatient substance abuse
          Group therapy visit:  $40 copay
          Individual therapy visit:  $40 copay
          Prosthetic devices (braces, artificial limbs, etc.)
          Prosthetic devices:  20% of the cost
          Related medical supplies:  20% of the cost
          ** Additional Benefits **
          Inpatient mental health care
          For inpatient mental health care see the "Mental Health Care" section.
          ** Cost **
          Monthly premium, deductible, and limits on how much you pay for covered services
          Package 1: Preventive Dental Package
          Benefits include:
            • Preventive Dental
          Additional $15.00 per month. You must keep paying your Medicare Part B premium and your $50 monthly plan premium.
          This package does not have a deductible.
          Our plan has a coverage limit for certain benefits.
          ** Important Information **
          Package 1: Preventive Dental Package
          Benefits include:
            • Preventive Dental
          Additional $15.00 per month. You must keep paying your Medicare Part B premium and your $50 monthly plan premium.
          This package does not have a deductible.
          Our plan has a coverage limit for certain benefits.
          ** Cost **
          Package 2: Dental and Vision Package
          Benefits include:
            • Preventive Dental
            • Comprehensive Dental
            • Eyewear
          Additional $26.00 per month. You must keep paying your Medicare Part B premium and your $50 monthly plan premium.
          This package does not have a deductible.
          Our plan has a coverage limit for certain benefits.
          ** Important Information **
          Package 2: Dental and Vision Package
          Benefits include:
            • Preventive Dental
            • Comprehensive Dental
            • Eyewear
          Additional $26.00 per month. You must keep paying your Medicare Part B premium and your $50 monthly plan premium.
          This package does not have a deductible.
          Our plan has a coverage limit for certain benefits.
          ** Cost **
          Package 3: Enhanced Dental and Vision Package
          Benefits include:
            • Preventive Dental
            • Comprehensive Dental
            • Eyewear
          Additional $37.00 per month. You must keep paying your Medicare Part B premium and your $50 monthly plan premium.
          This package does not have a deductible.
          Our plan has a coverage limit for certain benefits.
          ** Important Information **
          Package 3: Enhanced Dental and Vision Package
          Benefits include:
            • Preventive Dental
            • Comprehensive Dental
            • Eyewear
          Additional $37.00 per month. You must keep paying your Medicare Part B premium and your $50 monthly plan premium.
          This package does not have a deductible.
          Our plan has a coverage limit for certain benefits.




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          • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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          • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
          • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
          • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
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          • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
          • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
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          • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
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          • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
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          • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
          .