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Anthem MediBlue Dual Access (PPO D-SNP) By Anthem Blue Cross and Blue Shield



Anthem MediBlue Dual Access (PPO D-SNP) H4909 028 0 is a 2023 Medicare Advantage Special Needs Plan plan by Anthem Blue Cross and Blue Shield. This plan from Anthem Blue Cross and Blue Shield works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up 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. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Anthem MediBlue Dual Access (PPO D-SNP) H4909-028 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.







2023 Medicare Special Needs Plan Details

Plan Name:Anthem MediBlue Dual Access (PPO D-SNP)
Plan ID:H4909 028 0
Special Needs Type:Dual-Eligible
Provider:Anthem Blue Cross and Blue Shield
Plan Year:2023
Plan Type:Local PPO
Monthly Premium C+D:$28.70
Part C Premium:$0
Part D (Drug) Premium:$28.70
Part D Supplemental Premium$0
Total Part D Premium:$28.70
Drug Deductible:$315.00
Tiers with No Deductible:0
Benchmark:not below the regional benchmark
Type of Medicare Health Plan:Enhanced Alternative
Drug Benefit Type:Enhanced
Gap Coverage:No
Similar Plan: H4909-018


The Anthem MediBlue Dual Access (PPO D-SNP) H4909-028 is available to residents to Medicare eligible seniors in Missouri. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Anthem MediBlue Dual Access (PPO D-SNP) 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.



How much does Anthem MediBlue Dual Access (PPO D-SNP) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Anthem Blue Cross and Blue Shield charges a $0 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.


Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Anthem MediBlue Dual Access (PPO D-SNP) has a monthly drug premium of $28.70 and a $315.00 drug deductible. This Anthem Blue Cross and Blue Shield plan offers a $28.70 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. 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 $28.70. The Part D Total Premium is the addition of 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 2023 once you and your plan provider have spent $4660 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 not offer additional coverage through the gap.


Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Anthem MediBlue Dual Access (PPO D-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.20 for 75% low-income subsidy $14.30 for 50% and $21.50 for 25%.


Full Assistance Premium:$0
75% Assistance Premium:$7.20
50% Assistance Premium:$14.30
25% Assistance Premium:$21.50


H4909-028 Formulary and Drug Coverage

Anthem MediBlue Dual Access (PPO D-SNP) 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 Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy		 Copay
Nonpreferred
Pharmacy
Tier 1 $10 $10
Tier 2 $20 $20
Tier 3 $47 $47
Tier 4 $95 $100
Tier 5 28% 28%
Tier 6 $10 $10
The complete Anthem MediBlue Dual Access (PPO D-SNP) H4909-028 Formulary
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits

The benefit information provided is a summary of what Anthem MediBlue Dual Access (PPO D-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Anthem Blue Cross and Blue Shield helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

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


Contact lenses


In-Network Vision$0 copay
Out-of-Network Vision$0 copay


Eyeglass frames


In-Network Vision$0 copay
Out-of-Network Vision$0 copay


Eyeglass lenses


Out-of-Network Vision$0 copay
In-Network Vision$0 copay


Eyeglasses (frames and lenses)


In-Network Vision$0 copay
Out-of-Network Vision$0 copay


Other


VisionNot covered


Routine eye exam


In-Network Vision$0 copay
Out-of-Network Vision$0 copay


Upgrades


In-Network Vision$0 copay
Out-of-Network Vision$0 copay



In-Network Transportation$0 copay
Out-of-Network Transportation$0 copay
In-Network Skilled Nursing Facility$0 copay
Out-of-Network Skilled Nursing Facility40% per stay


Occupational therapy visit


In-Network Rehabilitation services$0 copay
Out-of-Network Rehabilitation services20% coinsurance


Physical therapy and speech and language therapy visit


In-Network Rehabilitation services$0 copay
Out-of-Network Rehabilitation services20% coinsurance


Cleaning


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay


Dental x-ray(s)


Out-of-Network Preventive dental$0 copay
In-Network Preventive dental$0 copay


Fluoride treatment


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental$0 copay


Oral exam


Out-of-Network Preventive dental$0 copay
In-Network Preventive dental$0 copay



Out-of-Network Preventive care20% coinsurance
In-Network Preventive care$0 copay
Out-of-Network Outpatient hospital coverage40% coinsurance per visit
In-Network Outpatient hospital coverage$0 copay
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo


Inpatient hospital - psychiatric


In-Network Mental health services$0 copay
Out-of-Network Mental health services40% per stay


Outpatient group therapy visit


In-Network Mental health services$0 copay
Out-of-Network Mental health services20% coinsurance


Outpatient group therapy visit with a psychiatrist


In-Network Mental health services$0 copay
Out-of-Network Mental health services20% coinsurance


Outpatient individual therapy visit


Out-of-Network Mental health services20% coinsurance
In-Network Mental health services$0 copay


Outpatient individual therapy visit with a psychiatrist


Out-of-Network Mental health services20% coinsurance
In-Network Mental health services$0 copay


Chemotherapy


In-Network Medicare Part B drugs$0 copay
Out-of-Network Medicare Part B drugs20% coinsurance


Other Part B drugs


In-Network Medicare Part B drugs$0 copay
Out-of-Network Medicare Part B drugs20% coinsurance


Diabetes supplies


Out-of-Network Medical equipment/supplies$0 copay
In-Network Medical equipment/supplies$0 copay


Durable medical equipment (e.g., wheelchairs, oxygen)


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item


Prosthetics (e.g., braces, artificial limbs)


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$12,450 In and Out-of-network
$8,300 In-network
Out-of-Network Inpatient hospital coverage40% per stay
In-Network Inpatient hospital coverage$0 copay


Fitting/evaluation


Out-of-Network Hearing$0 copay
In-Network Hearing$0 copay


Hearing aids


Out-of-Network Hearing$0 copay
In-Network Hearing$0 copay


Hearing exam


Out-of-Network Hearing20% coinsurance
In-Network Hearing$0 copay



Health plan deductible$0
In-Network Ground ambulance$0 copay
Out-of-Network Ground ambulance20% coinsurance


Foot exams and treatment


In-Network Foot care (podiatry services)$0 copay
Out-of-Network Foot care (podiatry services)20% coinsurance


Routine foot care


In-Network Foot care (podiatry services)$0 copay
Out-of-Network Foot care (podiatry services)$0 copay


Emergency


Emergency care/Urgent care$0 copay


Urgent care


Emergency care/Urgent care$0 copay


Primary


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits20% coinsurance per visit


Specialist


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits20% coinsurance per visit


Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance


Diagnostic tests and procedures


Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0 copay


Lab services


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance


Outpatient x-rays


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging20% coinsurance


Diagnostic services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental$0 copay


Endodontics


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental$0 copay


Extractions


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental$0 copay


Non-routine services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental$0 copay


Periodontics


Out-of-Network Comprehensive dental$0 copay
In-Network Comprehensive dental$0 copay


Prosthodontics, other oral/maxillofacial surgery, other services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental$0 copay


Restorative services


Out-of-Network Comprehensive dental$0 copay
In-Network Comprehensive dental$0 copay



In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No




CMS Star Ratings


Is Anthem MediBlue Dual Access (PPO D-SNP) a good plan? Anthem MediBlue Dual Access (PPO D-SNP) received 3 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Special Needs Plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare Anthem MediBlue Dual Access (PPO D-SNP) performance among several different plans.

2022 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with H4909-028 Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Anthem Blue Cross and Blue Shield

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes


Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Anthem MediBlue Dual Access (PPO D-SNP) requires you to live in that plan’s service area. The service area is listed below:

State: Medicare Missouri




Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.