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 Wisconsin. This plan received an overall rating of 4 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 $0.00. 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 $195.00 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 $8950.00 (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 $8950.00 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 $195 deductible for prescription drugs. After meeting the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and the pharmacy you use. For example, in the initial coverage phase, preferred generic drugs have a $5 copay at preferred pharmacies, while standard mail orders have no copay. The plan also offers a specialty tier with no copay. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Anthem Medicare Advantage (PPO) plan offers a wide array of benefits with varying costs. For inpatient hospital stays, you'll pay a copay, with the amount depending on the type of service and the length of stay. Outpatient services, including primary care, have copays ranging from no copay to $295. The plan also includes coverage for ambulance and transportation services, emergency services, preventive, hearing, vision, and dental services. Many services like routine hearing and vision exams, and dental services have no copay. Other services like home health, and skilled nursing facilities also have no copay for a certain amount of days.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $370 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you pay a $295 copay for days 1-5, and no copay for days 6-90. Additional days for both services 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 are covered by the Anthem Medicare Advantage (PPO) plan, including all outpatient hospital services with a copay between $0 and $295, and observation services with a $295 copay. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Substance Abuse Services have a $40 copay for both individual and group sessions. Outpatient Blood Services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Medicare Advantage (PPO) plan, and requires prior authorization. You will pay a $40 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Anthem Medicare Advantage (PPO), including ground and air ambulance services with a $310 copay, and transportation services to a plan-approved health-related location with no copay for up to 60 one-way trips per year. 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 under the Anthem Medicare Advantage (PPO) plan. Emergency Services have a $90 copay, Urgently Needed Services have a $30 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $90 copay. Worldwide Emergency Services has a maximum plan benefit coverage of $100,000.
Primary Care See details
Primary Care, Chiropractic, Occupational Therapy, Physician Specialist, Mental Health Specialty, Podiatry, Other Health Care Professional, Psychiatric, Physical Therapy and Speech-Language Pathology, Additional Telehealth Benefits and Opioid Treatment Program Services are covered. Primary Care Physician Services and Additional Telehealth Benefits have no copay, Chiropractic Services, Individual and Group Sessions for Mental Health Specialty Services, Physician Specialist Services, Individual and Group Sessions for Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, and Opioid Treatment Program Services have a $20 or $40 copay, and Occupational Therapy Services and Podiatry Services have a copay between $0 and $40.
Preventive Services See details
Preventive services include coverage for annual physical exams with no copay, and additional services like Personal Emergency Response System (PERS), Fitness Benefit, and Home and Bathroom Safety Devices and Modifications. Other services like Health Education, In-Home Safety Assessment, Medical Nutrition Therapy, and others are not covered.
Hearing Services See details
The Anthem Medicare Advantage (PPO) plan covers hearing exams with a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a yearly maximum of $1500, and OTC hearing aids are covered with no copay and a yearly maximum of $300.
Vision Services See details
The Anthem Medicare Advantage (PPO) plan covers vision services, including eye exams with a copay of $0-$40 and eyewear with no copay. Routine eye exams have no copay, and eyewear has a combined maximum benefit of $350 every year.
Dental Services See details
Dental Services are covered, including oral exams, dental x-rays, and other diagnostic and preventive services with no copay, as well as orthodontic services with no copay up to a $1,000 annual maximum. Restorative services, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are covered with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance ranges from 0% to 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 is covered by Anthem Medicare Advantage (PPO), including Durable Medical Equipment (DME) with 0% to 20% coinsurance and Prosthetics/Medical Supplies - Non-Medicare benefit with coinsurance for Medicare-covered devices and supplies. Diabetic Equipment is covered, with no copay for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts, and 20% coinsurance for Medical Supplies.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Anthem Medicare Advantage (PPO). Diagnostic Procedures/Tests have a copay between $0 and $150, while Lab Services have no copay. Diagnostic Radiological Services have a copay between $50 and $225. Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $50 copay.
Home Health Services See details
Home Health Services are covered by the Anthem Medicare Advantage (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
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 for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Anthem Medicare Advantage (PPO) plan. There is no copay for days 1-20, and a $203 copay for days 21-100. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services for the Anthem Medicare Advantage (PPO) plan covers over-the-counter items and other services. Over-the-counter items have no copay, and a maximum benefit coverage amount of $50 every three months, and other services have no copay. Acupuncture, meal benefits, 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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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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