Anthem Medicare Advantage (PPO)
Health Insurance Company: Anthem Blue Cross and Blue Shield
Medicare Advantage Plan Details
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $35 copay per visit
Out-of-network: $60 copay per visit
Out-of-network: 35% coinsurance
Emergency Room
$90 copay per visit (always covered)
Ambulance Coverage
In-network: $350 copay
Out-of-network: $350 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0-140 copay
Out-of-network: 35% coinsurance
Medicare-covered lab services: In-network: $0-15 copay
Out-of-network: 35% coinsurance
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $130-200 copay
Out-of-network: 35% coinsurance
Medicare-covered x-ray services: In-network: $50-110 copay
Out-of-network: 35% coinsurance
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-300 copay per visit
Out-of-network: 35% coinsurance per visit
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $350 per day for days 1 through 7
$0 per day for days 8 through 90
Out-of-network: 35% per stay
Inpatient hospital psychiatric:
In-network: $440 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: 35% per stay
Rehabilitation Coverage
Occupational therapy services:
In-network: $30 copay
Out-of-network: 35% coinsurance
Physical therapy and speech and language therapy services:
In-network: $30 copay
Out-of-network: 35% coinsurance
Urgent Care Coverage
$45 copay per visit (always covered)
Skilled Nursing Facility (SNF)
In-network: $0 per day for days 1 through 20
$196 per day for days 21 through 100
Out-of-network: 35% per stay
Mental Health Coverage
Medicare-covered individual sessions: In-network: $40 copay
Out-of-network: 35% coinsurance
Medicare-covered group sessions: In-network: $40 copay
Out-of-network: 35% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: In-network: $0 copay
Out-of-network: 20% coinsurance
Prophylaxis (cleaning): In-network: $0 copay
Out-of-network: 20% coinsurance
Dental x-rays: In-network: $0 copay
Out-of-network: 20% coinsurance
Vision Benefits
Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: $0 copay
Eyewear:
Contact Lenses: In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses: In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $40 copay
Out-of-network: $60 copay
Hearing aids:
Hearing aids (all types): In-network: $0 copay
Out-of-network: $0 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$4.00 copay (30-day supply)
$12.00 copay (90-day supply)
Tier 2: Generic
$13.00 copay (30-day supply)
$39.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$126.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$95.00 copay (30-day supply)
$285.00 copay (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$9.00 copay (30-day supply)
$27.00 copay (90-day supply)
Tier 2: Generic
$18.00 copay (30-day supply)
$54.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$100.00 copay (30-day supply)
$300.00 copay (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$84.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$95.00 copay (30-day supply)
$190.00 copay (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
Plan Links
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