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 OH. 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 no drug deductible. Your prescription medication coverage will start immediately.
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:
Sign up for Anthem Medicare Advantage (PPO)
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Drug Coverage
The Anthem Medicare Advantage (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $9 copay at preferred pharmacies, while standard mail order has no copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Anthem Medicare Advantage (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays that vary depending on the service. Emergency, primary care, hearing, vision, dental, and home health services are covered. The plan also includes coverage for ambulance, partial hospitalization, and home infusion services. Diagnostic and radiological services, as well as skilled nursing facility stays, are covered, with different copays and coinsurance. Some services, such as preventive care, dental, and OTC items, have no copay.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For days 1-5, there is a $375 copay, and days 6-90 have no copay; there is no coinsurance.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $375, and observation services with a $375 copay. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay, and Outpatient Substance Abuse Services have a $45 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Medicare Advantage (PPO) plan, but requires prior authorization. There is a $40 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services, and transportation services to plan-approved health-related locations. Ground and air ambulance services each have a $245 copay, while transportation services to plan-approved health-related locations have no copay and are limited 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. Emergency Services and Worldwide Emergency Coverage have a $125 copay, Urgently Needed Services has a $40 copay, and Worldwide Emergency Transportation and Worldwide Urgent Coverage also have a $125 copay.
Primary Care See details
The Anthem Medicare Advantage (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $45 copay, mental health specialty services with a $45 copay, podiatry services with a copay between $0 and $45, other health care professional services with a copay between $0 and $20, psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a $45 copay, additional telehealth benefits with no copay, and opioid treatment program services with a $45 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, and other services such as Personal Emergency Response System (PERS), Glaucoma Screening, and Diabetes Self-Management Training with no copay. Other benefits such as Health Education, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, and Telemonitoring Services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $45 copay, routine hearing exams with no copay, fitting/evaluation for hearing aids with no copay, and prescription hearing aids with a plan-specified amount per year. OTC hearing aids are covered with no copay.
Vision Services See details
The Anthem Medicare Advantage (PPO) plan covers vision services, including eye exams with a copay between $0 and $45, and eyewear with no copay. Eyewear has a combined maximum benefit of $150 every year.
Dental Services See details
Dental Services are covered, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics, all with no copay. These services have a maximum plan benefit coverage of $1,000 per year, and orthodontic services are covered under diagnostic and preventive dental.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Anthem Medicare Advantage (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has no copay and a coinsurance between 0% and 20%, 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 are covered by the Anthem Medicare Advantage (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay between $50 and $375, and Outpatient X-Ray Services have a $50 copay. Therapeutic Radiological Services have a minimum coinsurance of 20%.
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, but the specific services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by 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. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Anthem Medicare Advantage (PPO) plan covers Over-the-Counter (OTC) items with no copay, a maximum benefit of $55.00 every three months, and offers a meal benefit with no copay. Acupuncture, 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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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