A non-government entity
Anthem Medicare Advantage (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Anthem Medicare Advantage (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Anthem Medicare Advantage (PPO) in 2025, please refer to our full plan details page.
Anthem Medicare Advantage (PPO) is a PPO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Select Counties in NY. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Anthem Medicare Advantage (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Anthem Medicare Advantage (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Anthem Medicare Advantage (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $76.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $395.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $9000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $9000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Anthem Medicare Advantage (PPO) plan has a $395.00 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs at a preferred pharmacy, the copay is $2.00. For standard generic drugs, you will pay 20% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The Anthem Medicare Advantage (PPO) plan offers comprehensive coverage with varying costs for different services. Inpatient hospital stays have a copay, but many services have no copay, including preventive services like annual physical exams, and dental services. This plan covers a range of services, including outpatient, emergency, and primary care, with copays ranging from $10 to $125 for many services. Additional benefits include home health services with no copay, and coverage for medical equipment, diagnostic and radiological services, and skilled nursing facilities.
Inpatient Hospital See details
The Anthem Medicare Advantage (PPO) plan covers inpatient hospital stays with a copay of $372 for days 1-5, and no copay for days 6-90, for both acute and psychiatric care. Additional days for both acute and psychiatric care are covered with no copay. Non-Medicare-covered stays and upgrades for inpatient hospital-acute and non-Medicare-covered stays for inpatient hospital-psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a 20% coinsurance and no copay for outpatient hospital services, and a 20% coinsurance for observation services. Ambulatory Surgical Center (ASC) Services have no copay and a 15% coinsurance. Outpatient Substance Abuse Services, including individual and group sessions, have a $40 copay. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $40 copay, and prior authorization is required.
Ambulance and Transportation Services See details
The Anthem Medicare Advantage (PPO) plan covers ambulance services, including ground ambulance with a $275 copay, and air ambulance with 20% coinsurance. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered by the Anthem Medicare Advantage (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
The Anthem Medicare Advantage (PPO) plan covers primary care physician services with a $10 copay, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $50 copay, mental health specialty services with a $40 copay for individual and group sessions, other health care professional services with a copay between $10 and $20, psychiatric services with a $40 copay for individual and group sessions, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with no copay, and opioid treatment program services with a $40 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for services like annual physical exams with no copay, and additional preventive services like glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit, all with no copay. Other services like health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing Services with Anthem Medicare Advantage (PPO) include hearing exams with a $50 copay, but routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $50 and eyewear with no copay. Contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered by Anthem Medicare Advantage (PPO) with no copay, but orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery are not covered. Medicare dental services require prior authorization.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Anthem Medicare Advantage (PPO) plan. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Anthem Medicare Advantage (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits are covered under the Anthem Medicare Advantage (PPO) plan. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests and lab services, are covered, with copays ranging from $0 to $80. Radiological services are also covered, with copays up to $150 for diagnostic services and a 20% coinsurance for therapeutic services; outpatient X-rays have a $40 copay.
Home Health Services See details
Home Health Services are covered by the Anthem Medicare Advantage (PPO) plan with no copay and no coinsurance, though additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Anthem Medicare Advantage (PPO) plan, but the specific services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required, and the copay for covered services is listed elsewhere in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Anthem Medicare Advantage (PPO). For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items with no copay, a maximum plan benefit of $35.00 every three months, and coverage for Nicotine Replacement Therapy (NRT) and Naloxone. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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