Skip to search Skip to main content

Anthem MediBlue Dual Connect (HMO D-SNP)

Anthem Blue Cross and Blue Shield
Anthem MediBlue Dual Connect (HMO D-SNP) H9525-012 Plan Details
3.5 out of 5 stars

Anthem MediBlue Dual Connect (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H9525-012.

$18.90
Monthly Premium

Anthem MediBlue Dual Connect (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H9525-012.

Anthem Blue Cross and Blue Shield
Anthem MediBlue Dual Connect (HMO D-SNP) H9525-012 Plan Details
3.5 out of 5 stars

Anthem MediBlue Dual Connect (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield.
Plan ID: H9525-012.

$18.90
Monthly Premium

Wisconsin Counties Served

Adams Brown Burnett Columbia Green Kenosha Ashland Barron Bayfield Buffalo Calumet Chippewa Clark Crawford Dane Dodge Door Douglas Dunn Eau Claire Florence Fond Du Lac Forest Gogebic Grant Green Lake Iowa Iron Jefferson Juneau Kewaunee La Crosse Lafayette Langlade Lincoln Manitowoc Marathon Marinette Marquette Menominee Milwaukee Monroe Oconto Oneida Outagamie Ozaukee Pepin Pierce Polk Portage Price Racine Richland Rock Rusk Sauk Sawyer Shawano Sheboygan Taylor Trempealeau Vernon Vilas Walworth Washburn Washington Waukesha Waupaca Waushara Winnebago Wood

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8300
Out-of-Network: N/A
Initial Coverage Limit $4660
Catastrophic Coverage Limit $7,400
Primary Care Doctor Visit
In-Network:
$0.00 copay
Specialty Doctor Visit
In-Network:
$0.00 copay
Inpatient Hospital Care
In-Network:
Days: 1-10: $125.00 per day, per admission / Days: 11-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Urgent Care
Urgent Care: $20.00 copay
Emergency Room Visit
Emergency Care: $90.00 copay
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance Transportation
Ground Ambulance: 20% coinsurance Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem MediBlue Dual Connect (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Medicare Covered Chiropractic Services: 20% coinsurance
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: 20% coinsurance
X-Rays: 20% coinsurance
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: 20% coinsurance
Diagnostic Radiological Services: 20% coinsurance
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days: 1-10: $125.00 per day, per admission / Days: 11-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $0.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: 20% coinsurance
Observation Services: 20% coinsurance
Ambulatory Surgical Center: 15% coinsurance
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $0.00 copay
Over-the-counter (OTC) Items
This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $200 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $0.00 copay
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
Skilled Nursing Facility Care
In-Network:
Medicare-defined Cost Share

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:
Preventive Dental Services: $0.00 copay
This plan covers: 2 oral exam(s), 2 cleaning(s), 1 dental X-ray(s), 1 fluoride treatment(s) every year.

Medicare Covered Dental: $0.00 copay
Comprehensive Dental Services: $0.00 copay
This plan covers up to a $2,000.00 allowance for covered comprehensive dental services every year.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:
Medicare Covered Eye Exam: $0.00 copay
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: $0.00 copay
Routine Eye Wear: $0.00 copay
This plan covers up to $200.00 for eyeglasses or contact lenses every year.

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:
Medicare Covered Hearing Exam: $0.00 copay
Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount.
This plan covers 1 routine hearing exam(s) and hearing aid fitting/evaluation(s) every year. $3,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year.

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services
Back to Plans in Wisconsin
A couple uses their laptop computer while having coffee

Find Medicare Advantage Plans

Visit MedicareAdvantage.com to compare multiple Medicare Advantage plans, side by side. 

Visit site