5

5 out of 5 stars* for plan year 2024

Plan ID: H5422-013

What You Need to Know:

  • Anthem MediBlue Extra (HMO) is a Medicare Advantage Health Maintenance Organization Local HMO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $30, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is $445 (Tier 1 excluded from the Deductible.).
  • The plan includes an out-of-pocket maximum of $5,900 per year (in-network).
  • Anthem MediBlue Extra (HMO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is $445 (Tier 1 excluded from the Deductible.).
  • This plan's Part D Initial Coverage Limit is $30.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$30

Monthly Premium

Medicare Plan Features
Monthly Premium: $29.80
Part C Premium: $0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$29.80 $0 $29.80 $0 $29.80 $445.0 1.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local HMO
Similar Plan: H5422-014
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $5,900
Annual Deductible: $445 (Tier 1 excluded from the Deductible.)
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Harris, Georgia: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
less than 10 members 3.5 out of 5 Stars. 5 out of 5 Stars. 3 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,708 drugs
Number of Members Enrolled in this Plan in Harris, Georgia: 822 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$0.00 $29.80 $0.00 $29.80
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$0.00 $22.30 $22.30 $14.90 $14.90 $7.40 $7.40
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
306 $0.00 609 $10.00 942 $47.00 1061 $95.00 700 25%

Other Medicare Advantage Plans in Harris, Georgia

Plan Name Type Premium MOOP Rx Deduct. Rating
Humana Honor (PPO) (2023)Local PPO *$6,700$-
4
HumanaChoice H5216-241 (PPO) (2023)Local PPO$7,550$445
4
Anthem MediBlue Access (PPO) (2023)Local PPO$5,900$95
4
UnitedHealthcare Medicare Advantage Patriot (Regional PPO (2023)Regional PPO *$6,700$-
5
HumanaChoice R3392-002 (Regional PPO) (2023)Regional PPO$6,700$340
4
Anthem MediBlue Access Basic (PPO) (2023)Local PPO$6,700$150
4
UnitedHealthcare Medicare Advantage Choice (Regional PPO) (2023)Regional PPO$6,700$295
5
Anthem MediBlue Core (HMO) (2023)Local HMO *$7,550$-
5
Anthem MediBlue Essential (HMO) (2023)Local HMO$3,450$95
5
HumanaChoice R3392-001 (Regional PPO) (2023)Regional PPO *$6,700$-
4
Allwell Medicare (HMO) (2023)Local HMO$7,550$280
5
UnitedHealthcare Medicare Advantage Choice Plan 1 (PPO) (2023)Local PPO$6,700$275
5
Anthem MediBlue Plus (HMO) (2023)Local HMO$6,700$150
5
HumanaChoice H5216-203 (PPO) (2023)Local PPO$7,550$0
4
Aetna Medicare Preferred Premium Plan (PPO) (2023)Local PPO$6,900$195
New plan - not yet rated.
AARP Medicare Advantage Walgreens (HMO) (2023)Local HMO$6,700$275
5
Lasso Healthcare Growth Plus (MSA) (2023)MSA *$-$-
4
HumanaChoice H5216-154 (PPO) (2023)Local PPO$7,550$400
4
WellCare Dividend (HMO) (2023)Local HMO$6,700$200
5
Lasso Healthcare Growth (MSA) (2023)MSA *$-$-
4
Aetna Medicare Eagle Plan (PPO) (2023)Local PPO *$6,900$-
New plan - not yet rated.
Humana Gold Plus H4141-017 (HMO) (2023)Local HMO$7,550$0
4
WellCare Premier (PPO) (2023)Local PPO$4,900$75
5
WellCare Patriot (HMO-POS) (2023)Local HMO *$3,400$-
5
HumanaChoice H5216-142 (PPO) (2023)Local PPO$6,700$250
4
WellCare Endurance (PPO) (2023)Local PPO$4,900$0
5
HumanaChoice H5216-157 (PPO) (2023)Local PPO *$6,700$-
4
WellCare Prime (PPO) (2023)Local PPO$5,100$0
5
WellCare Compass (HMO) (2023)Local HMO$3,450$445
5
WellCare Value (HMO) (2023)Local HMO$3,450$0
5
Aetna Medicare Freedom Plan (PPO) (2023)Local PPO$6,900$250
New plan - not yet rated.
WellCare Flex Complete (PPO) (2023)Local PPO$2,500$0
5
Medicare Advantage Plans by Anthem Blue Cross and Blue Shield
Anthem MediBlue Access (PPO) (2023)Local PPO$5,900$95
4
Anthem MediBlue Access Basic (PPO) (2023)Local PPO$6,700$150
4
Anthem MediBlue Core (HMO) (2023)Local HMO *$7,550$-
5
Anthem MediBlue Essential (HMO) (2023)Local HMO$3,450$95
5
Anthem MediBlue Plus (HMO) (2023)Local HMO$6,700$150
5

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