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Anthem Medicare Advantage (PPO)

Anthem Blue Cross
Anthem Medicare Advantage (PPO) H3342-023 Plan Details
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Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross
Plan ID: H3342-023

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$83.00
Monthly Premium

Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross
Plan ID: H3342-023

Have Medicare questions?

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

Get Medicare Help
Anthem Blue Cross
Anthem Medicare Advantage (PPO) H3342-023 Plan Details
Not enough data available

Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross
Plan ID: H3342-023

Have Medicare questions?

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

Get Medicare Help
$83.00
Monthly Premium

New York Counties Served

Schoharie Washington Schenectady Clinton Passaic Columbia Rensselaer Delaware Fulton Saratoga Montgomery Greene Fairfield Warren

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $310
Out of Pocket Max In-Network: $6200
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:
$10.00 copay
Out-of-Network:
$50.00 copay
Specialty Doctor Visit
In-Network:
$50.00 copay
Out-of-Network:
$75.00 copay
Inpatient Hospital Care
In-Network:
Days 1-5: $372.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
40% coinsurance per stay
Urgent Care
Urgent Care: $60.00 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: $275.00 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: $20.00 copay
Out-of-Network:
Medicare Covered Chiropractic Services: $75.00 copay
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 - $20.00 copay
X-Rays: $40.00 copay - $80.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay - $80.00 copay
Diagnostic Radiological Services: $50.00 copay - $150.00 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 1-4: $395.00 per day, per admission / Days 5-90: $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:
$75.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: 20% coinsurance
Observation Services: 20% coinsurance
Ambulatory Surgical Center: 15% coinsurance
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
Over-the-counter (OTC) Items
This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $35 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: $50.00 copay
Out-of-Network:
Medicare Covered Podiatry Services: $75.00 copay
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
Medicare Covered Dental: $0.00 copay
Out-of-Network:
Medicare Covered Dental Services: 20% 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 - $50.00 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
Out-of-Network:
Medicare Covered Eye Exam: 40% coinsurance
Routine Eye Exam: $0.00 copay
Medicare Covered 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: $50.00 copay
Out-of-Network:
Medicare Covered Hearing Exam: $75.00 copay

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 Medicare Advantage (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $310 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $310 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $3.00
  • Standard retail $8.00
  • Standard mail order $3.00
Generic
  • Preferred cost-share retail $10.00
  • Standard retail $15.00
  • Standard mail order $10.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $310 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $6.00
  • Standard retail $16.00
  • Standard mail order $9.00
Generic
  • Preferred cost-share retail $20.00
  • Standard retail $30.00
  • Standard mail order $30.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $310 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $9.00
  • Standard retail $24.00
  • Standard mail order $9.00
Generic
  • Preferred cost-share retail $30.00
  • Standard retail $45.00
  • Standard mail order $30.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
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