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 Virginia. This plan received an overall rating of 3.5 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 $14.00. 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 has a $750.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $250.00 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 $11300.00 (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 $11300.00 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 a $250 annual drug deductible. For Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs, you will pay no copay when using preferred pharmacies or standard mail order. Standard pharmacies charge a copay ranging from $5 to $15 for Tier 1 drugs and $10 to $30 for Tier 2 drugs, while Tier 6 drugs have no copay even at standard pharmacies. For higher-tier medications, costs transition to a coinsurance model instead of flat copays. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 30% coinsurance across preferred, standard, and mail-order options. Note that Tier 5 specialty medications are limited to a 1-month supply.
Additional Benefits
The Anthem Medicare Advantage (PPO) plan offers robust core medical coverage with no copay and no coinsurance for primary care visits, routine preventive services, and home health care. For more intensive care, inpatient hospital stays require a $425 daily copay for the first five days of acute stays and no copay for subsequent days. Emergency room visits require a $115 copay and urgent care visits require a $40 copay, both of which feature no coinsurance. Additional benefits include routine dental, vision, and hearing care with no deductibles and no copay for routine exams. The plan provides allowances of up to $1,000 for prescription hearing aids and up to $125 for eyewear, alongside preventive dental care with no copay and comprehensive dental services at a 25% coinsurance. However, members should note that this plan does not cover certain supplemental benefits such as fitness programs, acupuncture, or over-the-counter items.
Inpatient Hospital See details
Anthem Medicare Advantage (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $425 daily copay for the first five days of acute stays and the first four days of psychiatric stays, with no copay for subsequent days. Prior authorization is required, and non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Anthem Medicare Advantage (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and blood services with no copay. Outpatient hospital services have a copay of $0 to $425, while outpatient substance abuse sessions require a $40 copay, with prior authorization needed for several services.
Partial Hospitalization See details
Partial hospitalization is covered by Anthem Medicare Advantage (PPO) with a $40.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Anthem Medicare Advantage (PPO) covers ambulance services with a $350 copay and no coinsurance for both ground and air transport, subject to prior authorization. Transportation services are partially covered with no copay or coinsurance for up to 60 one-way trips per year to plan-approved health-related locations, though transportation to any health-related location is not covered.
Emergency Services See details
Anthem Medicare Advantage (PPO) covers emergency room visits with a $115 copay and no coinsurance, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $100,000 maximum limit, with each service requiring a $115 copay and no coinsurance.
Primary Care See details
Anthem Medicare Advantage (PPO) provides primary care and telehealth services with no copay and no coinsurance, while specialist visits, therapy, and mental health services require copays up to $45 and no coinsurance. Chiropractic and podiatry services are not covered under this plan.
Preventive Services See details
Preventive services are partially covered by Anthem Medicare Advantage (PPO) with no copay and no coinsurance for covered benefits, including annual physical exams and kidney disease education. However, several supplemental sub-services are not covered, including fitness benefits, weight management, alternative therapies, health education, and personal emergency response systems.
Hearing Services See details
Anthem Medicare Advantage (PPO) covers hearing services with no deductible, offering routine exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $45 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to $1,000 annually—excluding inner ear, outer ear, and over-the-ear types—and over-the-counter hearing aids are covered with no copay and no coinsurance up to $300 yearly.
Vision Services See details
Anthem Medicare Advantage (PPO) vision services are partially covered with no deductibles, offering routine eye exams with no copay and no coinsurance up to a $69 annual limit, while other eye exams are not covered. Covered eyewear, including lenses and frames, also features no copay and no coinsurance up to a $125 annual limit, but upgrades are not covered.
Dental Services See details
Anthem Medicare Advantage (PPO) partially covers dental services up to a $1,000 annual limit, offering preventive and diagnostic care with no copay and no coinsurance. Covered comprehensive dental services require no copay and a 25% coinsurance, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Anthem Medicare Advantage (PPO) with no copay and no coinsurance, though prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while Medicare Part B chemotherapy and other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Anthem Medicare Advantage (PPO) 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 prosthetic devices and medical supplies with no copay and a 20% coinsurance. Diabetic supplies and therapeutic shoes are covered with no copay and no coinsurance, though select equipment may require prior authorization or use of specified manufacturers.
Diagnostic and Radiological Services See details
Anthem Medicare Advantage (PPO) covers diagnostic and radiological services with prior authorization, featuring no coinsurance for diagnostic services, no copay for lab tests, and a $0 to $140 copay for diagnostic procedures. Radiological services require a $50 copay for X-rays, diagnostic radiological copays starting at $50, and a 20% coinsurance for therapeutic services.
Home Health Services See details
Anthem Medicare Advantage (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Anthem Medicare Advantage (PPO) with no copay and no coinsurance, though prior authorization is required. While some services are covered, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Anthem Medicare Advantage (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. Patients pay no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Anthem Medicare Advantage (PPO) plan, as acupuncture, over-the-counter (OTC) items, and meal benefits are all excluded from coverage.
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