A non-government entity
Anthem I MaineHealth Advantage Access (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Anthem I MaineHealth Advantage Access (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Anthem I MaineHealth Advantage Access (PPO) in 2025, please refer to our full plan details page.
Anthem I MaineHealth Advantage Access (PPO) is a PPO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Select Counties in Maine. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Anthem I MaineHealth Advantage Access (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 I MaineHealth Advantage Access (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 I MaineHealth Advantage Access (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $2.00. 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 $1000.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $400.00 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 $9550.00 (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 $9550.00 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 I MaineHealth Advantage Access (PPO) plan has a $400 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic and specialty drugs, there is no copay. Standard generic drugs have 20-25% coinsurance, and preferred brand drugs have 35% coinsurance. Non-preferred drugs have 28% coinsurance.
Additional Benefits
The Anthem I MaineHealth Advantage Access (PPO) plan offers comprehensive coverage with a focus on outpatient and preventative services. Many services have no copay, including primary care visits, preventive services, and routine eye exams. The plan covers dental services with no copay for many procedures, along with hearing and vision benefits. For inpatient hospital stays, you'll pay a copay, with the amount varying by the type of stay and the length of time. Emergency and ambulance services are covered, but with copays and coinsurance. The plan also includes coverage for home health services, skilled nursing facilities, and various outpatient services.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, you will pay a $325 copay for days 1-7, and no copay for days 8-90. For Inpatient Hospital Psychiatric, you will pay a $325 copay for days 1-6, and no copay for days 7-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered. Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $325, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $40 copay for both individual and group sessions, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem I MaineHealth Advantage Access (PPO) plan, and requires prior authorization. You will pay a $45 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Anthem I MaineHealth Advantage Access (PPO). Ground ambulance services have a $295 copay, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered by Anthem I MaineHealth Advantage Access (PPO). Emergency Services have a $125 copay, while Urgently Needed Services have a $35 copay. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay.
Primary Care See details
Primary Care Physician Services have no copay, while Chiropractic Services have a $20 copay, and Routine Chiropractic Care is not covered. Occupational Therapy Services have a $40 copay, and Physician Specialist Services have a $45 copay. Individual and group sessions for Mental Health and Psychiatric Services both have a $40 copay. Physical Therapy and Speech-Language Pathology Services have a $40 copay, Additional Telehealth Benefits have no copay, and Opioid Treatment Program Services have a $40 copay.
Preventive Services See details
Preventive Services include Medicare-covered services with no copay, an annual physical exam with no copay, and additional preventive services. Additional preventive services have a copay, and some services like health education and in-home safety assessments are not covered. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit all have no copay.
Hearing Services See details
Hearing exams have a $45 copay, and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered up to $2,000 per year with no copay for all types of prescription hearing aids, while OTC hearing aids have no copay and are covered up to $300 per year.
Vision Services See details
Vision Services include eye exams and eyewear. Eye exams have a copay between $0 and $45, while routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses, have no copay, but upgrades are not covered.
Dental Services See details
The Anthem I MaineHealth Advantage Access (PPO) plan covers a range of dental services. There is no copay for 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. The plan has a $1,500 maximum benefit per year for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have 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 under the Anthem I MaineHealth Advantage Access (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by Anthem I MaineHealth Advantage Access (PPO), with Durable Medical Equipment (DME) subject to a 0-20% coinsurance, and Prosthetic Devices and Medical Supplies both subject to a 20% coinsurance. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay, while DME for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a minimum copay of $0 and a maximum copay of $80 for Diagnostic Procedures/Tests, and a $0 copay for Lab Services. Diagnostic Radiological Services have a copay of at most $325, and Therapeutic Radiological Services have a coinsurance of at most 20%, while Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by Anthem I MaineHealth Advantage Access (PPO) 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 not covered by the Anthem I MaineHealth Advantage Access (PPO) plan. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other Services include Medicare Community Resource Support with no copay. However, acupuncture, over-the-counter items, 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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