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 2026, 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 2026.
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 $10.00. 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 $350.00 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 $10100.00 (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 $10100.00 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 features an annual drug deductible of $350. Under this plan, you will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs at preferred, standard, and standard mail order pharmacies. Tier 2 generic drugs are also highly affordable, featuring no copay for standard mail orders and copays starting at $9 for a one-month supply at preferred retail pharmacies. For brand-name and specialty medications, the plan utilizes a coinsurance cost-sharing model. You will pay a 20% to 25% coinsurance for Tier 3 preferred brand drugs, while Tier 4 non-preferred drugs require a 30% coinsurance. Tier 5 specialty drugs are covered with a 29% coinsurance for a one-month supply across preferred, standard, and standard mail order pharmacies.
Additional Benefits
The Anthem Medicare Advantage (PPO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, including no copay for primary care visits, preventive services, and home health care. Specialist visits require a $45 copay, while emergency room services incur a $130 copay. For inpatient hospital stays, members pay a $375 daily copay for days 1 through 5, with no copay for subsequent days. Supplemental benefits include routine dental, vision, and hearing services, which feature no copays for routine exams alongside annual coverage limits. Members also benefit from no copay on up to 60 one-way transportation trips to approved health locations and no copay for diabetic supplies. Other essential services, such as durable medical equipment and dialysis, require no copay and coinsurance ranging from 0% to 20%.
Inpatient Hospital See details
Anthem Medicare Advantage (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 and beyond. This benefit is partially covered because prior authorization is required, and upgrades as well as non-Medicare-covered stays are not covered.
Outpatient Services See details
Anthem Medicare Advantage (PPO) covers outpatient services with no coinsurance, featuring a $0 to $375 copay for outpatient hospital services and a $375 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse services require a $45 copay per session with no coinsurance.
Partial Hospitalization See details
Anthem Medicare Advantage (PPO) covers partial hospitalization services with a $40.00 copay and no coinsurance. Prior authorization is required for these services to be covered.
Ambulance and Transportation Services See details
Anthem Medicare Advantage (PPO) covers ground and air ambulance services with a $245 copay and no coinsurance per trip. Transportation services are partially covered, offering up to 60 one-way trips per year to plan-approved health-related locations with no copay and no coinsurance, though transportation to any other health-related location is not covered.
Emergency Services See details
Anthem Medicare Advantage (PPO) covers emergency services with a $130 copay and no coinsurance, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with a $130 copay and no coinsurance per service, up to a maximum plan benefit limit of $100,000.
Primary Care See details
Anthem Medicare Advantage (PPO) covers primary care and telehealth visits with no copay and no coinsurance, while chiropractic services are not covered. Specialist visits, therapies, mental health, psychiatric, and opioid treatment require a $45 copay and no coinsurance, while podiatry and other healthcare professionals range from no copay up to a $45 copay and no coinsurance.
Preventive Services See details
Preventive services are covered by Anthem Medicare Advantage (PPO) with no copay and no coinsurance for annual physical exams, kidney disease education, and screenings. Additional preventive benefits are partially covered, offering remote access and up to $500 annually for home safety devices, while sub-services such as fitness benefits, health education, weight management, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by Anthem Medicare Advantage (PPO), featuring no copay or coinsurance for routine exams, fitting evaluations, and OTC hearing aids, while Medicare-covered exams require a $45 copay and no coinsurance. Annual coverage limits apply, and prescription hearing aids are covered up to $2,000, though inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Anthem Medicare Advantage (PPO) features partially covered vision services with no copays, no coinsurance, and no deductibles for routine eye exams and eyewear, subject to annual limits of $69 for exams and $150 for eyewear. Other eye exam services and eyewear upgrades are not covered.
Dental Services See details
Anthem Medicare Advantage (PPO) offers partially covered dental services with an annual maximum benefit of $1,000, featuring no copay and no coinsurance for preventive care. Comprehensive services require no copay and a 25% coinsurance, while implant services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Anthem Medicare Advantage (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and coinsurance ranging from 0% to 20%.
Dialysis Services See details
Anthem Medicare Advantage (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Anthem Medicare Advantage (PPO) covers durable medical equipment with no copay and 0% to 20% coinsurance, and prosthetics and medical supplies with no copay and 20% coinsurance. Diabetic equipment, supplies, and therapeutic shoes are also covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Anthem Medicare Advantage (PPO), with prior authorization required. Diagnostic services feature no coinsurance, offering lab services with no copay and diagnostic tests with a $0 to $95 copay, while radiological services require a $50 minimum copay for diagnostic radiology, an $80 copay for X-rays, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Anthem Medicare Advantage (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Anthem Medicare Advantage (PPO) covers some cardiac rehabilitation services with no coinsurance, though prior authorization is required. However, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered, with copayments ranging from $15.00 to $35.00.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Anthem Medicare Advantage (PPO) with no coinsurance and do not require a prior three-day hospital stay, though prior authorization is needed. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, but additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Anthem Medicare Advantage (PPO) partially covers other services with no copay and no coinsurance, including chronic illness meal benefits, Medicare Community Resource Support, and a $30 quarterly over-the-counter allowance. Acupuncture is not covered under this benefit.
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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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