2022 Anthem MediBlue Access Basic (PPO)

Anthem MediBlue Access Basic (PPO) H4909-016 is a 2022 Medicare Advantage Plan or Part-C by Anthem Blue Cross and Blue Shield available to residents in Missouri. This plan includes additional prescription drug (Part-D) coverage. The Anthem MediBlue Access Basic (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,900 out-of-pocket. This can be a extremely nice safety net.

Anthem MediBlue Access Basic (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Anthem Blue Cross and Blue Shield works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Anthem MediBlue Access Basic (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Anthem Blue Cross and Blue Shield and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Anthem Blue Cross and Blue Shield except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Anthem Blue Cross and Blue Shield Medicare Advantage Plan Costs

Anthem MediBlue Access Basic (PPO) Part-C Premium

Anthem Blue Cross and Blue Shield charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H4909-016 Part-D Deductible and Premium

Anthem MediBlue Access Basic (PPO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Anthem Blue Cross and Blue Shield plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Anthem Blue Cross and Blue Shield above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Anthem Blue Cross and Blue Shield Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Anthem Blue Cross and Blue Shield plan does offer additional coverage through the gap.

H4909-016 Formulary or Drug Coverage

Anthem MediBlue Access Basic (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Anthem MediBlue Access Basic (PPO) H4909-016 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$4	$9
Tier 2	$13	$18
Tier 3	$42	$47
Tier 4	$95	$100
Tier 5	33%	33%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 Anthem MediBlue Access Basic (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$1,000 annual deductible

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$145-225 copay
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0-165 copay
Lab services	40% coinsurance (Out-of-Network)
Lab services	$0-20 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)
Outpatient x-rays	$50-115 copay

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Doctor Visits

Primary	$5 copay per visit
Primary	$50 copay per visit (Out-of-Network)
Specialist	$60 copay per visit (Out-of-Network)
Specialist	$40 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$35 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$60 copay (Out-of-Network)
Foot exams and treatment	$0-40 copay
Routine foot care	$0 copay
Routine foot care	$60 copay (Out-of-Network)

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Ground Ambulance

$275 copay (Out-of-Network)
$275 copay

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	20% coinsurance (Out-of-Network)
Hearing aids	$0 copay (Out-of-Network)
Hearing aids	$0 copay
Hearing exam	$40 copay
Hearing exam	$60 copay (Out-of-Network)

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Inpatient Hospital Coverage

$295 per day for days 1 through 7 $0 per day for days 8 through 90
50% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	40% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	40% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	40% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$275 per day for days 1 through 6 $0 per day for days 7 through 90
Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Outpatient group therapy visit	$60 copay (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit with a psychiatrist	$60 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	$60 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	$60 copay (Out-of-Network)

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MOOP

$10,000 In and Out-of-network $4,900 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$0-285 copay per visit
50% coinsurance per visit (Out-of-Network)

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Package #1

Deductible
Monthly Premium	$19.00

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Package #2

Deductible
Monthly Premium	$28.00

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Package #3

Deductible
Monthly Premium	$59.00

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Preventive Care

40% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	$0 copay
Cleaning	20% coinsurance (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	20% coinsurance (Out-of-Network)
Fluoride treatment	20% coinsurance (Out-of-Network)
Fluoride treatment	$0 copay
Oral exam	$0 copay
Oral exam	20% coinsurance (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	$40 copay
Occupational therapy visit	$60 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$60 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

50% per stay (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Other	Not covered
Routine eye exam	$0 copay (Out-of-Network)
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Anthem MediBlue Access Basic (PPO) H4909

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Anthem MediBlue Access Basic (PPO) Plans Performance

Health Plan Customer Service Rating for Anthem MediBlue Access Basic (PPO)

Anthem MediBlue Access Basic (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Anthem MediBlue Access Basic (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.