Summary of benefits ehealthinsurance

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Summary of Benefits

for Anthem MediBlue Plus (HMO) and Anthem MediBlue Select (HMO)

Available in: Hartford County

Plan year: January 1, 2017 ? December 31, 2017

In this section, you'll learn about some of the services we cover, what you'll pay for those services and other important details to help you choose the right Medicare Advantage plan for you. While the benefit information provided does not list every service that we cover or list every limitation or exclusion, you can get a complete list of those services. Just give us a call and ask for the Evidence of Coverage.

Have questions? Here's how to reach us and our hours of operation:

If you are not a member of this plan, please call toll free 1-800-238-1143 (TTY: 711), and follow the instructions to be connected to a representative. If you are a member of this plan, call our toll-free Customer Service number at 1-866-673-4157 (TTY: 711). 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. You can learn more about us on our website at shop.

Y0114_17_27849_U_057 CMS Accepted 10/01/2016 60800MUSENMUB_057 H5854_010-000_007-000_CT-HMO

Anthem MediBlue Plus (HMO) | Anthem MediBlue Select (HMO)

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What you should know about our plans

Anthem MediBlue Plus (HMO) and Anthem MediBlue Select (HMO) are Medicare Advantage and prescription drug plans, which includes hospital, medical and prescription drug benefits in one plan. To join these plans, you must be entitled to Medicare Part A, enrolled in Medicare Part B and live in our service area.

Our service area includes: CT: Hartford

With these plans, you must use a provider in the plan's network. If you use providers that are not in our network, the plan may not pay for these services.

You can find a doctor in the network online -- visit shop and choose Find a Doctor. (Be sure to check that the doctor displays as "In-Network" for these plans.) Or you can call Customer Service and request a copy of the provider directory.

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Anthem MediBlue Plus (HMO) | Anthem MediBlue Select (HMO)

What do we cover?

Like all Medicare health plans, we cover everything that Original Medicare covers -- Part A (hospital services) and Part B (medical services), plus more. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less (see benefits section for more details).

Medicare Part D drugs and Part B drugs (such as chemotherapy and some drugs administered by your provider).

To see if your drugs are covered, you can view the plan's Formulary (list of covered Part D prescription drugs) and any restrictions on our website at shop. Or you can call us for a copy of the Formulary.

What are my drug costs?

Our plan groups each medication into one of six "tiers." The amount you pay depends on the drug's tier and what stage of the benefit you have reached (refer to The four stages of coverage).

How to find out what your covered drugs will cost:

Step 1: Find your drug on the Formulary.

Step 2: Next, identify the drug tier.

Step 3: Then, go to the Prescription Drug Benefits section further in this booklet to match the tier.

Anthem MediBlue Plus (HMO) | Anthem MediBlue Select (HMO)

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Can I use any pharmacy to fill my covered prescriptions?

To receive the lowest out-of-pocket costs on your covered Part D drugs, you must generally use a pharmacy in our network. If you use a pharmacy that is not in our network, you may pay more for your covered drugs.

You may be able to save even more money at pharmacies with preferred cost sharing

We've worked with certain network pharmacies to further reduce prices, so you can save more on your covered drugs. Having available preferred pharmacies does not mean you can't use other pharmacies in our network (pharmacies with standard cost sharing), but you may pay more at a pharmacy with standard cost-sharing. Pharmacies with preferred cost-sharing have lower copays and coinsurance amounts for non-specialty drugs than pharmacies with standard cost-sharing.

For a complete listing of network pharmacies, refer to our plan's Pharmacy Directory on our website shop (under Useful Tools, select Find a Pharmacy). Next to the pharmacy name, you will see a preferred cost-sharing indicator (a symbol). Or you can give us a call, and we will send you a copy.

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Anthem MediBlue Plus (HMO) | Anthem MediBlue Select (HMO)

How can I learn more about Medicare or compare my choices with other plans?

Visit our online Medicare tutorial at .

Refer to your current Medicare & You handbook. You can view it online at or call Medicare for a copy at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.

If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or you can go online to and use the Medicare Plan Finder.

Now that you are familiar with how Medicare works and some of the benefits included in our plans, it's time to consider the type of plan you may need. On the following pages, you can review our available plans with varying coverage levels to help you choose the right plan for you.

Be in the know

Before you continue, here are a few important things to know as you review our available plan options:

Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

Anthem MediBlue Plus (HMO) | Anthem MediBlue Select (HMO)

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Anthem MediBlue Plus (HMO)

Anthem MediBlue Select (HMO)

How much is my premium?

$26.00 per month

$0.00 per month

You must continue to pay your Medicare Part B premium.

How much is my deductible?

This plan does not have a medical deductible.

$360.00 per year for Part D prescription drugs

Drugs listed on Tier 1: Preferred Generic and Tier 6: Select Care Drugs are excluded from the Part D deductible

This plan does not have a medical deductible.

$223.00 per year for Part D prescription drugs

Drugs listed on Tier 1: Preferred Generic and Tier 6: Select Care Drugs are excluded from the Part D deductible

Is there a limit on how much I will pay for my covered medical services? (does not include Part D drugs)

$6,100 per year from in-network providers

$6,700 per year from in-network providers

Like all Medicare health plans, our plans protect you by having yearly limits on your out-of-pocket costs for medical and hospital care.

Your limit for services received from in-network providers will count toward the yearly limit. If you reach the limit on out-of-pocket costs, you will not have to pay any out-of-pocket costs for the rest of the year for covered in-network Part A and Part B services.

You will still need to pay your monthly premiums (if you have one) and cost sharing for your Part D prescription drugs.

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Anthem MediBlue Plus (HMO) | Anthem MediBlue Select (HMO)

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