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 $75.00. 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 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $2 copay at preferred pharmacies and a $7 copay at standard pharmacies. For specialty drugs, you will have no copay.
Additional Benefits
The Anthem Medicare Advantage (PPO) plan offers a wide array of benefits. This plan covers inpatient hospital stays with a copay, and outpatient services with copays or coinsurance. Emergency, primary care, preventive, vision, dental, and home health services are covered, with varying costs like copays, coinsurance, or no cost. Additional benefits include hearing, ambulance, and medical equipment services. This plan also covers home infusion, dialysis, and diagnostic services. There is coverage for skilled nursing facilities, and other services like over-the-counter items.
Inpatient Hospital See details
Inpatient hospital services are covered, including acute and psychiatric care, with prior authorization required. For Inpatient Hospital-Acute, you pay a $372 copay for days 1-5, and no copay for days 6-90; additional days are covered with no copay. For Inpatient Hospital Psychiatric, you pay a $372 copay for days 1-6, and no copay for days 7-90; additional days are covered with no copay. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a 20% coinsurance, observation services with a 20% coinsurance and no copay, and ambulatory surgical center (ASC) services with a 15% coinsurance and no copay. Individual and group sessions for outpatient substance abuse have a $40 copay. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Medicare Advantage (PPO) plan, with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Anthem Medicare Advantage (PPO) plan. Ground Ambulance Services have a $275 copay, while Air Ambulance Services have a 20% coinsurance; however, Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Anthem Medicare Advantage (PPO) plan. Emergency Services and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have a $125 copay, while Urgently Needed Services have a $55 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 (prior authorization required), occupational therapy services with a $40 copay (prior authorization required), physician specialist services with a $50 copay (prior authorization required), mental health specialty services with a $40 copay for individual and group sessions (prior authorization required), physical therapy and speech-language pathology services with a $40 copay (authorization required), additional telehealth benefits with no copay, and opioid treatment program services with a $40 copay (prior authorization required). Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, and additional preventive services with copays for fitness benefits and remote access technologies. Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visits are also covered with no copay. However, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), and other services are not covered.
Hearing Services See details
Hearing Services are partially covered by the Anthem Medicare Advantage (PPO) plan. Hearing exams have 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 routine eye exams with no copay, but eyewear is only partially covered. Eyewear benefits do not cover contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, or upgrades.
Dental Services See details
Dental Services are covered under the Anthem Medicare Advantage (PPO) plan, with no copay for Medicare Dental Services. Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. 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 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits are covered by Anthem Medicare Advantage (PPO), including Durable Medical Equipment (DME) with 0-20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay, while Diabetic Equipment has copays, and Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures/tests with a copay between $0 and $80, lab services with no copay, and diagnostic radiological services with a copay between $40 and $150. Therapeutic radiological services have a 20% coinsurance, and outpatient X-ray services 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, but 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, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Anthem Medicare Advantage (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items with no copay and a maximum benefit of $35 every three months. 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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