Medicare Plan Lookup Official CMS data · Contract Year 2026
CMS 2026 data

2026 Medicare plan code

H2628-003

Medicare Plan

Anthem Full Dual Advantage (HMO D-SNP) · Anthem Blue Cross and Blue Shield · HMO · Select counties in OH

Full CMS plan ID: H2628-003-000

H2628-003-000 is the full CMS identifier for the H2628-003 Medicare plan. Common searches include H2628 003 and H2628003.

Historical 2026 record. Benefits and service areas shown apply to that year.

2026

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2026 plan record

Anthem Full Dual Advantage (HMO D-SNP)

H2628-003-000 Select counties in OH HMO Dual-Eligible

At-a-glance

Quick view

01

In-network

Inpatient hospital

inpatient coinsurance is selected but its percentage is missing

02

Emergency transport

Ambulance

Ground · in-network20% coinsurance
Air · in-network20% coinsurance
03

Emergency services

Emergency room

$115 copay

04

Medical maximum

Maximum out-of-pocket

In-network$9,250
Combined in + outNot reported
05

Skilled care at home

Home health

In-network$0 copay
Out-of-networkNot separately reported
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0.20 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-network20% coinsurance
Out-of-networkNot separately reported

Specialist

In-network20% coinsurance
Out-of-networkNot separately reported

Preventive care

In-network$0 copay
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-network20% coinsurance
Out-of-networkNot separately reported

Laboratory services

In-network20% coinsurance
Out-of-networkNot separately reported

X-rays & standard imaging

In-network20% coinsurance
Out-of-networkNot separately reported

MRI, CT & PET imaging

In-network20% coinsurance
Out-of-networkNot separately reported
Urgent & hospital care6 benefits

Urgent care

In-networkCost share not reported
Out-of-networkNot separately reported

Emergency room

In-network$115 copay
Out-of-networkNot separately reported

Ground ambulance

In-network20% coinsurance
Out-of-networkNot separately reported

Air ambulance

In-network20% coinsurance
Out-of-networkNot separately reported

Outpatient hospital

In-network20% coinsurance
Out-of-networkNot separately reported

Outpatient surgery / ASC

In-network20% coinsurance
Out-of-networkNot separately reported
Recovery & therapy5 benefits

Home health

In-network$0 copay
Out-of-networkNot separately reported

Skilled nursing facility

In-networkCost share not reported
Out-of-networkNot separately reported

Cardiac & pulmonary rehabilitation

In-network20% coinsurance
Out-of-networkNot separately reported

Occupational therapy

In-network20% coinsurance
Out-of-networkNot separately reported

Physical & speech therapy

In-network20% coinsurance
Out-of-networkNot separately reported
Behavioral health2 benefits

Mental health services

In-network$105 copay
Out-of-networkNot separately reported

Substance use treatment

In-network$105 copay
Out-of-networkNot separately reported
Specialty care2 benefits

Podiatry

In-network$0 copay
Out-of-networkNot separately reported

Chiropractic

In-network20% coinsurance
Out-of-networkNot separately reported
Supplemental benefits7 benefits

Dental

In-network20% coinsurance
Out-of-networkNot separately reported

Vision

In-network$0 copay
Out-of-networkNot separately reported

Hearing

In-network$0 copay
Out-of-networkNot separately reported

Transportation

In-network$0 copay
Out-of-networkNot separately reported

Fitness & wellness

In-network$0 copay
Out-of-networkNot separately reported

Over-the-counter allowance

In-network$0 copay
Out-of-networkNot separately reported

Meals

In-network$0 copay
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$0 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$9,250
Combined in + outNot reported

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Network & referrals

HMO · Referrals: Not required · Out-of-network coverage: No

Prescription drugs6 tiers

Part D deductible

Not reported

Drug tier 1

$0 retail copay · 30-day supply

Drug tier 2

25% retail coinsurance · 30-day supply

Drug tier 3

25% retail coinsurance · 30-day supply

Drug tier 4

25% retail coinsurance · 30-day supply

Drug tier 5

25% retail coinsurance · 30-day supply

Drug tier 6

$0 retail copay · 30-day supply

Using this plan

Understand H2628-003-000

Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

Anthem Full Dual Advantage (HMO D-SNP) is a 2026 HMO offered by Anthem Blue Cross and Blue Shield in Select counties in OH. The CMS record does not indicate routine out-of-network coverage. The plan record does not require referrals.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
20% coinsurance
Specialist
20% coinsurance
Laboratory services
20% coinsurance

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
20% coinsurance
MRI, CT & PET imaging
20% coinsurance
Outpatient hospital
20% coinsurance

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$115 copay

Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Availability

Who can enroll

Service area
Select counties in OH (OH)
Plan type
HMO
Special Needs Plan
Dual-Eligible
Contract / plan
H2628-003
Coverage year
2026

This is a Dual-Eligible; enrollment requires the plan's specific eligibility criteria as well as residence in its service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

Dental20% coinsurance
Vision$0 copay
Hearing$0 copay
Over-the-counter allowance$0 copay
Fitness & wellness$0 copay
Transportation$0 copay
Meals$0 copay

Plan-specific answers

Frequently asked questions

Where is H2628-003-000 available?

Anthem Full Dual Advantage (HMO D-SNP) is listed for Select counties in OH (OH). This is a Dual-Eligible; enrollment requires the plan's specific eligibility criteria as well as residence in its service area.

What is the in-network maximum out-of-pocket limit for H2628-003-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $9,250. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H2628-003-000?

The listed consolidated Part C and Part D premium is $0.20 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H2628-003-000?

The plan record lists $115 copay.

Does H2628-003-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness, and other supplemental benefits. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2026

Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H2628-003-000 fits

Full CMS plan ID
H2628-003-000
Contract
H2628
Base plan code
H2628-003
Segment
000
Carrier
Anthem Blue Cross and Blue Shield
Plan type
HMO
Service area
Select counties in OH (OH)

County/service-area foundation

CMS service-area entries

Named county entries are tied to this exact contract, plan, and segment in CMS Landscape data. County codes are enriched from the aligned CMS contract service-area release where a match exists.

  • Adams, OH
  • Allen, OH
  • Ashland, OH
  • Ashtabula, OH
  • Athens, OH
  • Auglaize, OH
  • Belmont, OH
  • Brown, OH
  • Carroll, OH
  • Champaign, OH
  • Coshocton, OH
  • Crawford, OH

47 additional service-area entries are retained in the data record.

Same CMS contract

H2628-001-000 Anthem I MyCare Ohio Full Dual Advantage (HMO D-SNP) Select counties in OH · HMO H2628-004-000 Anthem Full Dual Advantage 2 (HMO D-SNP) Select counties in OH · HMO H2628-005-000 Anthem Dual Advantage (HMO D-SNP) Select counties in OH · HMO

About this code

What H2628-003-000 identifies

H2628-003-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H2628-003, H2628 003, or the compact full CMS ID H2628003000 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.