Anthem I MaineHealth Advantage Access (PPO)
Anthem I MaineHealth Advantage Access (PPO) H9219-001 Plan Details
Anthem I MaineHealth Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem I MaineHealth
Plan ID: H9219-001
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$20.00
Monthly Premium
Anthem I MaineHealth Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem I MaineHealth
Plan ID: H9219-001
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $400 |
| Out of Pocket Max |
In-Network: $6350 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: 40% coinsurance |
| Specialty Doctor Visit | In-Network: $45.00 copay Out-of-Network: 40% coinsurance |
| Inpatient Hospital Care | In-Network: Days 1-7: $325.00 per day, per admission / Days 8-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Urgent Care | Urgent Care: $35.00 copay |
| Emergency Room Visit | Emergency Care: $90.00 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 | Ground Ambulance: $295.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Anthem I MaineHealth Advantage Access (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: $20.00 copay Out-of-Network: Medicare Covered Chiropractic Services: 40% coinsurance |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 40% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance Out-of-Network: 40% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay - $10.00 copay X-Rays: $20.00 copay - $40.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $80.00 copay Diagnostic Radiological Services: $100.00 copay - $200.00 copay Out-of-Network: Lab Services: 40% coinsurance X-Rays: 40% coinsurance Therapeutic Radiological Services: 40% coinsurance Outpatient Diagnostic Procedures/Tests: 40% coinsurance Diagnostic Radiological Services: 40% coinsurance |
| Home Health Care | In-Network: $0.00 copay Out-of-Network: 40% coinsurance |
| Mental Health Inpatient Care | In-Network: Days 1-6: $325.00 per day, per admission / Days 7-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $325.00 copay Observation Services: $325.00 copay Ambulatory Surgical Center: $325.00 copay Out-of-Network: Outpatient Hospital - Surgery: 40% coinsurance Observation Services: 40% coinsurance Ambulatory Surgical Center: 40% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Podiatry Services | In-Network: Medicare Covered Podiatry Services: $45.00 copay Out-of-Network: Medicare Covered Podiatry Services: 40% coinsurance |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day Out-of-Network: 40% coinsurance per stay |
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 $1,000 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: Copayment for Medicare Covered Comprehensive Dental $0.00 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 - $45.00 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 $150.00 for eyeglasses or contact lenses every year. Out-of-Network: Medicare Covered Eye Exam: 40% coinsurance Routine Eye Exam: $0.00 copay Medicare Covered Eye Wear: $0.00 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 $59.00 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 $2,000.00 maximum plan benefit for prescribed hearing aids every year. Out-of-Network: Medicare Covered Hearing Exam: 40% coinsurance 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: 40% coinsurance |
Prescription Drug Costs and Coverage
The Anthem I MaineHealth Advantage Access (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $400 (excludes Tiers 1, 2 and 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $400 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $400 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $400 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
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