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Anthem Medicare Advantage (PPO)

Anthem Blue Cross and Blue Shield
Anthem Medicare Advantage (PPO) H4909-014 Plan Details
3 out of 5 stars

Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4909-014

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4909-014

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Anthem Blue Cross and Blue Shield
Anthem Medicare Advantage (PPO) H4909-014 Plan Details
3 out of 5 stars

Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4909-014

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Virginia Counties Served

Henry Botetourt Carroll Montgomery Franklin Radford Pittsylvania Norton City Pulaski Bedford Grayson Wythe Bland Salem Lee Washington Scott Dickenson Wise Buchanan Galax City Staunton City Buena Vista City Alleghany Highland Rockbridge Covington City Lexington City Lynchburg City Danville City Clarke Manassas City Rappahannock Winchester City Greene Falls Church City Spotsylvania King and Queen Stafford Caroline Essex Orange Nelson King George Warren Lancaster Middlesex Frederick Page Madison Rockingham Fluvanna Augusta Louisa Richmond City Charlottesville City Nottoway York Amherst Amelia Buckingham Charles City Lunenburg James City Goochland Mathews Powhatan Chesterfield Suffolk City Southampton Williamsburg City Isle of Wight Northampton Portsmouth City Chesapeake City Virginia Beach City Norfolk City Floyd Brunswick Dinwiddie Petersburg City Emporia City Halifax Surry Prince Edward Greensville Sussex Colonial Heights City Franklin City Jefferson Charlotte Patrick Mecklenburg Giles Appomattox Roanoke Campbell Roanoke City

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $295
Out of Pocket Max In-Network: $7950
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
In-Network:
$0.00 copay
Out-of-Network:
$35.00 copay
Specialty Doctor Visit
In-Network:
$45.00 copay
Out-of-Network:
$60.00 copay
Inpatient Hospital Care
In-Network:
Days 1-5: $395.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Out-of-Network:
35% coinsurance per stay
Urgent Care
Urgent Care: $45.00 copay
Emergency Room Visit
Emergency Care: $110.00 copay
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000 per year.
Ambulance Transportation
Ground Ambulance: $350.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem Medicare Advantage (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Medicare Covered Chiropractic Services: $15.00 copay
Out-of-Network:
Medicare Covered Chiropractic Services: 35% coinsurance
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Out-of-Network:
35% coinsurance
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Out-of-Network:
35% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay - $15.00 copay
X-Rays: $50.00 copay - $110.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay - $140.00 copay
Diagnostic Radiological Services: $50.00 copay - $395.00 copay
Out-of-Network:
Lab Services: 35% coinsurance
X-Rays: 35% coinsurance
Therapeutic Radiological Services: 35% coinsurance
Outpatient Diagnostic Procedures/Tests: 35% coinsurance
Diagnostic Radiological Services: 35% coinsurance
Home Health Care
In-Network:
$0.00 copay
Out-of-Network:
35% coinsurance
Mental Health Inpatient Care
In-Network:
Days 1-4: $395.00 per day, per admission / Days 5-90: $0.00 per day, per admission
Out-of-Network:
35% coinsurance per stay
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $40.00 copay
Out-of-Network:
35% coinsurance
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $395.00 copay
Observation Services: $395.00 copay
Ambulatory Surgical Center: $345.00 copay
Out-of-Network:
Outpatient Hospital - Surgery: 35% coinsurance
Observation Services: 35% coinsurance
Ambulatory Surgical Center: 35% coinsurance
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $40.00 copay
Out-of-Network:
35% coinsurance
Over-the-counter (OTC) Items
This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $30 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts expire at the end of the calendar year.
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $45.00 copay
Out-of-Network:
Medicare Covered Podiatry Services: $60.00 copay
Skilled Nursing Facility Care
In-Network:
Days 1 - 20: $0.00 per day / Days 21 - 100: $214.00 per day
Out-of-Network:
35% coinsurance per stay

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
This plan covers up to a $1,000 allowance for covered preventive and comprehensive dental services every year.

In-Network:
Medicare Covered Dental: $0.00 copay
Preventive Dental Services: $0.00 copay
Comprehensive Dental Services: $0.00 copay

Out-of-Network:
Medicare Covered Dental: $0.00 copay
Non-Medicare Preventive Dental Services: 20% coinsurance
Non-Medicare Comprehensive Dental Services: 50% coinsurance

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:
Medicare Covered Eye Exam: $0.00 copay - $45.00 copay
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year. $69 maximum eye exam coverage amount.
Medicare Covered Eye Wear: $0.00 copay
Routine Eye Wear: $0.00 copay
This plan covers up to $125 for eyeglasses or contact lenses every year.
Out-of-Network:
Medicare Covered Eye Exam: $60.00 copay
Routine Eye Exam: $0.00 copay
Medicare Covered Eye Wear: $60.00 copay
Routine Eye Wear: $0.00 copay

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:
Medicare Covered Hearing Exam: $45.00 copay
Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount.
This plan covers 1 routine hearing exam up to a $59 maximum plan benefit every year. $300 maximum plan benefit for over-the-counter hearing aids OR 1 routine hearing aid fitting evaluation and a $1,000 maximum plan benefit for prescribed hearing aids every year.
Out-of-Network:
Medicare Covered Hearing Exam: $60.00 copay
Routine Hearing Exam: 20% coinsurance for routine hearing exam(s).

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services
Out-of-Network:
35% coinsurance

Prescription Drug Costs and Coverage

The Anthem Medicare Advantage (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $295 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $295 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $5.00
Generic
  • Preferred cost-share retail $2.00
  • Standard mail order $0.00
  • Standard retail $7.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Annual Drug Deductible $295 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $10.00
Generic
  • Preferred cost-share retail $4.00
  • Standard mail order $0.00
  • Standard retail $14.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Annual Drug Deductible $295 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $15.00
Generic
  • Preferred cost-share retail $6.00
  • Standard mail order $0.00
  • Standard retail $21.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
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