Anthem Medicare Advantage (PPO) - H4909-014-000

3 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield

Plan ID: H4909-014-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Virginia Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Virginia Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Enrollment may be limited to certain times of the year. See why you may be able to enroll.

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$295.00
Out-of-pocket maximum	$7,950.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$2,000.00
Primary care doctor visit	In-Network: $0.00 copay
Specialty doctor visit	In-Network: $45.00 copay
Inpatient hospital care	Out-of-Network: 35% coinsurance per stay
Urgent care	Urgent Care: $45.00 copay
Emergency room visit	Emergency Care: $110.00 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 per year.
Ambulance transportation	Ground Ambulance: $350.00 copay Per Trip Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem Medicare Advantage (PPO) covers a range of additional benefits. Learn more about Anthem Medicare Advantage (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Medicare Covered Chiropractic Services: 35% coinsurance
Diabetes supplies, training, nutrition therapy and monitoring	In-Network: Diabetic Supplies: $0.00 copay
Durable medical equipment (DME)	In-Network: 20% coinsurance
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Lab Services: $0.00 copay - $15.00 copay X-Rays: $50.00 copay - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $140.00 copay Diagnostic Radiological Services: $50.00 copay - $395.00 copay
Home health care	In-Network: $0.00 copay
Mental health inpatient care	In-Network: Days 1-4: $395.00 per day, per admission / Days 5-90: $0.00 per day, per admission
Mental health outpatient care	In-Network: Individual and Group Sessions: $40.00 copay
Outpatient services/surgery	Out-of-Network: Outpatient Hospital - Surgery: 35% coinsurance Observation Services: 35% coinsurance Ambulatory Surgical Center: 35% coinsurance
Outpatient substance abuse care	Out-of-Network: 35% coinsurance
Over-the-counter items	This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $30 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts expire at the end of the calendar year.
Podiatry services	In-Network: Medicare Covered Podiatry Services: $45.00 copay
Skilled Nursing Facility (SNF) care	Out-of-Network: 35% coinsurance per stay

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Dental care	This plan covers up to a $1,000 allowance for covered preventive and comprehensive dental services every year. In-Network: Medicare Covered Dental: $0.00 copay Preventive Dental Services: $0.00 copay Comprehensive Dental Services: $0.00 copay

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

Coverage	Details
Vision care	In-Network: Medicare Covered Eye Exam: $0.00 copay - $45.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. $69 maximum eye exam coverage amount. Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $125 for eyeglasses or contact lenses every year.

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing care	Out-of-Network: Medicare Covered Hearing Exam: $60.00 copay Routine Hearing Exam: 20% coinsurance for routine hearing exam(s).

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Preventive services and health/wellness education programs	Out-of-Network: 35% coinsurance

Prescription Drug Costs and Coverage

The Anthem Medicare Advantage (PPO) offers prescription drug coverage, with an annual drug deductible of $295.00 (excludes Tiers 1, 2, and 6)

Coverage & Cost 30 day supply 60 day supply 90 day supply
Coverage	Cost 30 day supply 60 day supply 90 day supply
Annual drug deductible	$295.00 (excludes Tiers 1, 2, and 6)
Tier 1	Preferred retail $0.00 Standard retail $5.00 Standard mail order $0.00
Tier 2	Preferred retail $2.00 Standard retail $7.00 Standard mail order $0.00
Tier 6	Preferred retail $0.00 Standard retail $0.00 Standard mail order $0.00
Annual drug deductible	$295.00 (excludes Tiers 1, 2, and 6)
Tier 1	Preferred retail $0.00 Standard retail $10.00 Standard mail order $0.00
Tier 2	Preferred retail $4.00 Standard retail $14.00 Standard mail order $0.00
Tier 6	Preferred retail $0.00 Standard retail $0.00 Standard mail order $0.00
Annual drug deductible	$295.00 (excludes Tiers 1, 2, and 6)
Tier 1	Preferred retail $0.00 Standard retail $15.00 Standard mail order $0.00
Tier 2	Preferred retail $6.00 Standard retail $21.00 Standard mail order $0.00
Tier 6	Preferred retail $0.00 Standard retail $0.00 Standard mail order $0.00

When reviewing Virginia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Virginia that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Virginia Counties Served

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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