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Anthem Full Dual Advantage (PPO D-SNP)

Anthem Blue Cross and Blue Shield
Anthem Full Dual Advantage (PPO D-SNP) H4036-032 Plan Details
4.5 out of 5 stars

Anthem Full Dual Advantage (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4036-032

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Anthem Full Dual Advantage (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4036-032

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
Anthem Blue Cross and Blue Shield
Anthem Full Dual Advantage (PPO D-SNP) H4036-032 Plan Details
4.5 out of 5 stars

Anthem Full Dual Advantage (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4036-032

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help
$0.00
Monthly Premium

Georgia Counties Served

Baldwin Peach Spalding Baker Houston Butts Upson Schley Taylor Jasper Wilkes Glascock Laurens Jones Warren Jefferson Pike Monroe Twiggs Hancock Taliaferro Lamar Washington Bibb Macon Wilkinson Crawford Russell Gwinnett Clayton Barrow Chatham Cobb Bartow Rockdale Henry Fulton Hall Dekalb Carroll Oconee Turner Tattnall Candler Dodge Clinch Clarke Johnson Elbert Muscogee Ben Hill Towns Oglethorpe Polk Effingham Chattahoochee Franklin Screven Tift Mcduffie Pierce Brantley Dooly Rabun Meriwether Evans Coffee Emanuel Bleckley Richmond Stewart Murray Long Charlton Union Marion Jenkins Greene Toombs Quitman Crisp Ware Stephens Pickens Wayne Montgomery Putnam Madison Habersham Heard Harris Atkinson Bryan Jackson Mcintosh Fannin Walton Banks Burke Lowndes Talbot Appling Catoosa Morgan Newton Lincoln Haralson Columbia Bacon Pulaski Webster Wilcox Telfair Hart Liberty Dawson Chattooga Gilmer Troup Irwin Lumpkin White Treutlen Wheeler Jeff Davis Coweta Paulding Bulloch Douglas Cherokee Forsyth

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay - 40% coinsurance
Specialty Doctor Visit
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay - 40% coinsurance
Inpatient Hospital Care
In-Network:
$0.00 copay per stay
Additional Hospital Days: Unlimited additional days
Out-of-Network:
Days 1-5: $0.00 - $305.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Urgent Care
Urgent Care: $0.00 copay
Emergency Room Visit
Emergency Care: $0.00 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 $100,000.00 per year.
Ambulance Transportation
In-Network:
Ground Ambulance: $0.00 copay
Air Ambulance: $0.00 copay
Out-of-Network:
$0.00 copay - 20% coinsurance for each covered, one-way ambulance trip by ground or water.
$0.00 copay -20% coinsurance for each air ambulance trip.

Health Care Services and Medical Supplies

Anthem Full Dual Advantage (PPO D-SNP) 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: $0.00 copay
Out-of-Network:
Medicare Covered Chiropractic Services: $0.00 copay - 40% coinsurance
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Out-of-Network:
$0.00 copay
Durable Medical Eqipment (DME)
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay - 40% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 copay
Therapeutic Radiological Services: $0.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 copay
Diagnostic Radiological Services: $0.00 copay
Out-of-Network:
Lab Services: $0.00 copay - 40% coinsurance
X-Rays: $0.00 copay - 40% coinsurance
Therapeutic Radiological Services: $0.00 copay - 40% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay - 40% coinsurance
Diagnostic Radiological Services: $0.00 copay - 40% coinsurance
Home Health Care
In-Network:
$0.00 copay
Out-of-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
$0.00 copay per stay
Additional Hospital Days: Unlimited additional days
Out-of-Network:
Days 1-5: $0.00 - $305.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $0.00 copay
Out-of-Network:
$0.00 copay - 40% coinsurance
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $0.00 copay
Observation Services: $0.00 copay
Ambulatory Surgical Center: $0.00 copay
Out-of-Network:
Outpatient Hospital - Surgery: $0.00 copay - 40% coinsurance
Observation Services: $0.00 copay - 40% coinsurance
Ambulatory Surgical Center: $0.00 copay - 40% coinsurance
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $0.00 copay
Out-of-Network:
$0.00 copay - 40% coinsurance
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $0.00 copay
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
Out-of-Network:
Medicare Covered Podiatry Services: $0.00 copay - 40% coinsurance
Routine Foot Care: $0.00 copay
Skilled Nursing Facility Care
In-Network:
$0.00 copay per stay
Out-of-Network:
Days 1 - 20: $0.00 per day / Days 21 - 100: $0.00 - $196.00 per day

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:
Preventive and Comprehensive Dental Combined Allowance
This plan covers up to $4,000 for covered preventive and comprehensive dental services every year.

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

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 40%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00

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
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year. $69.00 maximum eye exam coverage amount.
Medicare Covered Eye Wear: $0.00 copay
Routine Eye Wear: $0.00 copay
This plan covers up to $425.00 for eyeglasses or contact lenses every year.
Out-of-Network:
Medicare Covered Eye Exam: $0.00 copay - 40% coinsurance
Routine Eye Exam: $0.00 copay
Medicare Covered Eye Wear: $0.00 copay - 40% coinsurance
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: $0.00 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 $59.00 maximum plan benefit every year. $300.00 maximum plan benefit for over-the-counter hearing aids OR 1 routine hearing aid fitting evaluation and a $3,000.00 maximum plan benefit for prescribed hearing aids every year.
Out-of-Network:
Medicare Covered Hearing Exam: $0.00 copay - 40% coinsurance
Routine Hearing Exam: $0.00 copay 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:
$0.00 copay - 40% coinsurance

Prescription Drug Costs and Coverage

The Anthem Full Dual Advantage (PPO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Specialty Tier
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Specialty Tier
  • Preferred cost-share retail N/A
  • Standard mail order N/A
  • Standard retail N/A
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Specialty Tier
  • Preferred cost-share retail N/A
  • Standard mail order N/A
  • Standard retail N/A
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
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