Anthem Medicare Advantage 2 (PPO)

Anthem Blue Cross and Blue Shield
Anthem Medicare Advantage 2 (PPO) H4036-035 Plan Details
4 out of 5 stars

Anthem Medicare Advantage 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4036-035

Have Medicare questions?

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

$28.00
Monthly Premium

Anthem Medicare Advantage 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4036-035

Have Medicare questions?

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

Anthem Blue Cross and Blue Shield
Anthem Medicare Advantage 2 (PPO) H4036-035 Plan Details
4 out of 5 stars

Anthem Medicare Advantage 2 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4036-035

Have Medicare questions?

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

$28.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4950
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:
$40.00 copay
Specialty Doctor Visit
In-Network:
$35.00 copay
Out-of-Network:
$60.00 copay
Inpatient Hospital Care
In-Network:
Days 1-7: $295.00 per day, per admission / Days 8-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
30% 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: $295.00 copay

Health Care Services and Medical Supplies

Anthem Medicare Advantage 2 (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: $60.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Out-of-Network:
30% coinsurance
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Out-of-Network:
30% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay - $20.00 copay
X-Rays: $50.00 copay - $120.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay - $160.00 copay
Diagnostic Radiological Services: $140.00 copay - $225.00 copay
Out-of-Network:
Lab Services: 30% coinsurance
X-Rays: 30% coinsurance
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: 30% coinsurance
Diagnostic Radiological Services: 30% coinsurance
Home Health Care
In-Network:
$0.00 copay
Out-of-Network:
30% coinsurance
Mental Health Inpatient Care
In-Network:
Days 1-5: $295.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
30% coinsurance per stay
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $35.00 copay
Out-of-Network:
$60.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $295.00 copay
Observation Services: $295.00 copay
Ambulatory Surgical Center: $250.00 copay
Out-of-Network:
Outpatient Hospital - Surgery: 30% coinsurance
Observation Services: 30% coinsurance
Ambulatory Surgical Center: 30% coinsurance
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $35.00 copay
Out-of-Network:
30% coinsurance
Over-the-counter (OTC) Items
This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $65 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $0.00 copay - $35.00 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:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $203.00 per day
Out-of-Network:
30% 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 $2,500 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:
Coinsurance for Non-Medicare Covered Preventive Dental 20%
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 - $35.00 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 $300.00 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: $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: $35.00 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: $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:
30% coinsurance