Anthem Grocery (PPO)

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Anthem Grocery (PPO) is a PPO plan offered by Anthem Blue Cross and Blue Shield

Plan ID: H4036-033

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.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as Anthem Grocery (PPO) - H4036-033 by Anthem Blue Cross and Blue Shield as well as other Medicare Advantage plans available in your area.

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Georgia Counties Served

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

Basic Costs and Coverage

Coverage	Cost
Monthly Deductible	$295
Out of Pocket Max	In-Network: $9300 Out-of-Network: N/A
Initial Coverage Limit	$0
Catastrophic Coverage Limit	$2000
Primary Care Doctor Visit	Out-of-Network: $50.00 copay
Specialty Doctor Visit	In-Network: $30.00 copay
Inpatient Hospital Care	Out-of-Network: 40% coinsurance per stay
Urgent Care	Urgent Care: $35.00 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: $270.00 copay Per Trip Air Ambulance: $270.00 copay

Health Care Services and Medical Supplies

Anthem Grocery (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: $60.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring	In-Network: Diabetic Supplies: $0.00 copay
Durable Medical Equipment (DME)	Out-of-Network: 40% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays	In-Network: Lab Services: $0.00 copay X-Rays: $30.00 copay - $90.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $140.00 copay Diagnostic Radiological Services: $30.00 copay - $380.00 copay
Home Health Care	In-Network: $0.00 copay
Mental Health Inpatient Care	Out-of-Network: 40% coinsurance per stay
Mental Health Outpatient Care	Out-of-Network: $60.00 copay
Outpatient Services / Surgery	In-Network: Outpatient Hospital - Surgery: $380.00 copay Observation Services: $380.00 copay Ambulatory Surgical Center: $330.00 copay
Outpatient Substance Abuse Care	In-Network: Individual and Group Sessions: $30.00 copay Out-of-Network: 40% coinsurance
Over-the-counter (OTC) Items
Podiatry Services	In-Network: Medicare Covered Podiatry Services: $0.00 copay - $30.00 copay Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. Out-of-Network: Medicare Covered Podiatry Services: $60.00 copay Routine Foot Care: $60.00 copay
Skilled Nursing Facility Care	In-Network: Days 1 - 20: $0.00 per day / Days 21 - 100: $214.00 per day

Dental Benefits

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

Coverage	Cost
Dental Care	This plan covers up to a $1,500 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

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 - $30.00 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 $275 for eyeglasses or contact lenses every year.

Hearing Benefits

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

Coverage	Cost
Hearing Benefits	In-Network: Medicare Covered Hearing Exam: $30.00 copay Routine Hearing Exam: $0.00 copay for routine hearing exam(s). This plan covers 1 routine hearing exam up to a $59 maximum plan benefit every year.

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	Out-of-Network: 40% coinsurance

Prescription Drug Costs and Coverage

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

Coverage	Cost
Coverage & Cost
Annual Drug Deductible	$295 (excludes Tiers 1 and 2)
Preferred Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share retail $0.00
Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share retail $0.00
Annual Drug Deductible	$295 (excludes Tiers 1 and 2)
Preferred Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share retail $0.00
Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share retail $0.00
Annual Drug Deductible	$295 (excludes Tiers 1 and 2)
Preferred Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share retail $0.00
Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share retail $0.00

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