2018 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs
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1 2018 Plan Year Monthly Plan for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. The table below shows you how much you will pay for your monthly plan premium based on your state, county and your percentage of the subsidized amount. This does not include any Medicare Part B premium you may have to pay. California Los Angeles, Orange, & San Bernardino 100% 75% 50% 25% Anthem Value Plus (HMO) Anthem Value Plus (HMO) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 1
2 Anthem Value Plus (HMO) $54.00 $0.10 $9.00 $17.80 $26.70 Anthem Value Plus (HMO) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Value Plus (HMO) $48.00 $8.20 $16.50 $24.70 Anthem Value Plus (HMO) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino 100% 75% 50% 25% Anthem Diabetes (HMO SNP) Anthem Diabetes (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 2
3 Anthem Diabetes (HMO SNP) $55.00 $15.50 $24.40 $33.20 $42.10 Anthem Diabetes (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Diabetes (HMO SNP) $59.00 $13.20 $22.10 $30.90 $39.80 Anthem Diabetes (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino 100% 75% 50% 25% Anthem Heart (HMO SNP) Anthem Heart (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 3
4 Anthem Heart (HMO SNP) $55.00 $13.40 $22.30 $31.10 $40.00 Anthem Heart (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Heart (HMO SNP) $ % 75% $ % $ % $23.20 Anthem Heart (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino Anthem Breathe (HMO SNP) 100% 75% 50% 25% Anthem Breathe (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 4
5 Anthem Breathe (HMO SNP) $55.00 $19.50 $28.40 $37.20 $46.10 Anthem Breathe (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Breathe (HMO SNP) $59.00 $20.00 $28.90 $37.70 $46.60 Anthem Breathe (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino Anthem ESRD (HMO SNP) Anthem ESRD (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles & Santa Clara 5
6 Anthem Connect (HMO SNP) Anthem Connect (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & Santa Clara Anthem Touch (HMO SNP) 100% 75% 50% 25% Anthem Touch (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, San Bernardino, Santa Clara, San Benito, and Stanislaus Anthem StartSmart Plus (HMO SNP) Anthem StartSmart Plus (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, San Bernardino, Santa Clara, & San Benito 6
7 Anthem Connect Plus (HMO SNP) $33.00 $8.20 $16.50 $24.70 Anthem Connect Plus (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, San Bernardino, Santa Clara, San Benito, and Stanislaus If you aren t getting extra help, you can see if you qualify by calling: MEDICARE ( ), or TTY/TDD users should call hours a day, 7 days a week, Your State Medicaid Office, or The Social Security Administration at or TTY/TDD users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Customer Service at , TTY/TTD 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 to February 14, and Monday to Friday (except holidays) from February 15 to September 30. Our automated system is available anytime for self-service options, including after hours, weekends, and holidays. Anthem Blue Cross is an HMO/ HMO SNP plan with a Medicare contract. Enrollment in Anthem Blue Cross depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your insurance agent, Anthem or visit us on the web. ABCLIS18 Y0114_18_33174_U CMS Accepted (MM/DD/YYYY) 7
8 NOTICE OF NON-DISCRIMINATION We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We: Provide free aids and services to people with disabilities to communicate effectively with us, such as: o Qualifed sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provide free language services to people whose primary language is not English, such as: o Qualifed interpreters o Information written in other languages If you need these services, contact Member Services. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can fle a grievance with: Member Services, Appeals & Grievances, Park Plaza Drive, Suite 150, Mailstop 6150, Cerritos, CA 90703, , TTY 711. You can fle a grievance in person or by mail, fax, or . If you need help fling a grievance, Member Services Representative is available to help you. You can also fle a civil rights complaint with the U.S. Department of Health and Human Services, Offce for Civil Rights, electronically through the Offce for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Amharic Arabic Armenian Bengali (TTY: 711). Chinese (TTY: 711) English French ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711)
9 German Hindi Hmong (TTY: 711) (TTY: 711). Ilocano Japanese Korean Kru (Bassa) Mon-Khmer, Cambodian Navajo (TTY: 711) (TTY: 711) Persian (Farsi) Punjabi Russian Samoan Serbo-Croatian Spanish Syriac (TTY: 711). Tagalog Thai (TTY: 711) Urdu Vietnamese (TTY: 711). Y0114_18_32484_I _002 (09/01/2017).(TTY: 711) : NOND_CA_NV
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