1. Anthem MediBlue Coordination Plus (HMO) H0564-080-000
CMS Contract#-PBP-Segment#
N/A H
Plan Year
2015
2016
Service Area
CA: Los Angeles, Orange
In a select network
Plan Name
Anthem MediBlue Coordination Plus (HMO)
Plan Premium
$31.00
In-Network Out-of-Pocket Max
$6,700

2. Anthem MediBlue Coordination Plus (HMO) H0564-080-000
CMS Contract#-PBP-Segment#
N/A H
OUTPATIENT CARE
In-Network Outpatient Lab Services
20% coinsurance
In-Network Outpatient Diagnostic Procedures/Tests
In-Network Outpatient Therapeutic Radiological Services
In-Network Medicare Covered Dental
In-Network Medicare Covered Eye Exam
In-Network Medicare Covered Eye Wear
In-Network Medicare Covered Hearing Exam

3. Anthem MediBlue Coordination Plus (HMO) H0564-080-000
CMS Contract#-PBP-Segment#
N/A H
OUTPATIENT CARE
In-Network Durable Medical Equipment
20% coinsurance
Urgently Needed Services
Emergency Care
Ambulance

4. Anthem MediBlue Coordination Plus (HMO) H0564-080-000
CMS Contract#-PBP-Segment#
N/A H
SUPPLEMENTAL BENEFITS
In-Network Annual Physical Exam
$0.00 copay
In-Network Preventive Dental (Routine) Benefit
$0.00 copay for 2 oral exam(s) every year. $0.00 copay for 2 cleaning(s) every year. $0.00 copay for 1 dental x-ray(s) every year.
In-Network Comprehensive Dental (Routine) Benefit
$0.00 copay $ benefit allowance every three months. This is in addition to the routine preventive dental benefit offered on this plan.
In-Network Routine Eye Exams
$0 copay for 1 routine eye exam(s) every year.
In-Network Routine Eye Wear
$0 copay for eye glasses (lenses and frames) or contact lenses every two years. $100 limit for eye glasses or contact lenses every two years.

5. Anthem MediBlue Coordination Plus (HMO) H0564-080-000
CMS Contract#-PBP-Segment#
N/A H
SUPPLEMENTAL BENEFITS
In-Network Routine Hearing
$0.00 copay for 1 routine hearing exam(s) every year. $0.00 copay for 1 fitting-evaluation for a hearing aid every year. $0.00 copay for hearing aids. $2, maximum plan benefit for hearing aids every year.
In-Network Hearing Aids
$0.00 copay $2, maximum hearing aid benefit per year. This plan offers unlimited hearing aids up to the maximum benefit allowance.
In-Network Routine Podiatry
$0.00 copay
In-Network Routine Podiatry (Limits)
6 routine foot care visit(s) every year.

6. Anthem MediBlue Coordination Plus (HMO) H0564-080-000
CMS Contract#-PBP-Segment#
N/A H
SUPPLEMENTAL BENEFITS
LiveHealth Online (Y/N)
Yes
Personal Emergency Response System (Y/N) No
Over the Counter Supplemental Coverage (OTC) Benefit
This plan covers certain approved non-prescription over-the-counter drugs and health related items; up to $45 every three months
Silver Sneakers (Y/N)
Telemonitoring (Y/N)
Transportation Benefit
This plan offers coverage for 24 routine transportation services every year.
Emergency/Urgent Care Worldwide Coverage Benefit
This plan covers emergency services when traveling outside of the United States for less than six months. This benefit is limited to $25, per year for worldwide emergency services.

7. Anthem MediBlue Coordination Plus (HMO) H0564-080-000
CMS Contract#-PBP-Segment#
N/A H
Part D Benefits: Amounts for 30-day preferred retail; 30-day standard retail; 90-day mail order
Formulary
Core
Part D Deductible
$360.00
Applicable Part D Deductible Tiers
2, 3, 4 & 5
Initial Coverage Limit (ICL)
$3,310
Tier 1: Preferred Generic
$0.00; $0.00; $0.00
Tier 2: Generic
$7.00; $7.00; $21.00
Tier 3: Preferred Brand
$47.00; $47.00; $141.00
Tier 4: Nonpreferred Brand
$92.00; $97.00; $276.00
Tier 5: Specialty Tier
25%; 25%; N/A
Tier 6: Select Care Drugs
Gap Coverage
Tier 6: Select Care Drugs $0.00; $0.00; $0.00

8. Low Income Subsidy Categories and Cost Sharing/Copays
LIS Level
Description
Generic copay per Rx (our Tiers 1 , 2 & 6)
Brand copay per Rx (our Tiers 3, 4 & 5)
2015
2016
Level 1
Partial
$2.65
$2.95
$6.60
$7.40
Level 2
Full Subsidy
$1.20
$3.60
Level 3
Institutionalized
$0.00
Level 4
Minimal
Lesser of filed benefit or 15% of drug cost
Level 5
None (does not qualify for subsidy)
Filed benefit
The member pays the lesser of the LIS copay, filed benefit or actual cost of the drug (depending upon LIS level). A level 4 LIS beneficiary also has a responsibility to pay a Rx deductible of up to $74 (in 2016).