Anthem Medicare Advantage (Regional PPO)
Anthem Medicare Advantage (Regional PPO) R5941-014 Plan Details
Anthem Medicare Advantage (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: R5941-014
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Talk to a licensed agent today to find a plan that fits your needs.
$73.00
Monthly Premium
Anthem Medicare Advantage (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: R5941-014
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Anthem Medicare Advantage (Regional PPO) R5941-014 Plan Details
Anthem Medicare Advantage (Regional PPO) is a Regional PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: R5941-014
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$73.00
Monthly Premium
Ohio Counties Served
Darke
Preble
Clark
Champaign
Montgomery
Miami
Shelby
Greene
Stark
Hamilton
Franklin
Summit
Cuyahoga
Butler
Carroll
Brown
Union
Medina
Trumbull
Seneca
Ottawa
Warren
Fairfield
Lucas
Lake
Pickaway
Licking
Allen
Madison
Lorain
Geauga
Mahoning
Ashland
Tuscarawas
Clermont
Delaware
Morrow
Fulton
Portage
Wood
Columbiana
Crawford
Hardin
Henry
Huron
Paulding
Sandusky
Erie
Richland
Wyandot
Holmes
Wayne
Putnam
Hancock
Marion
Hocking
Perry
Auglaize
Van Wert
Clinton
Guernsey
Mercer
Coshocton
Logan
Jefferson
Noble
Lawrence
Williams
Athens
Scioto
Highland
Morgan
Fayette
Meigs
Pike
Washington
Jackson
Gallia
Monroe
Adams
Harrison
Vinton
Muskingum
Knox
Defiance
Ashtabula
Ross
Belmont
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $50 |
| Out of Pocket Max |
In-Network: $6050 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: $40.00 copay |
| Specialty Doctor Visit | In-Network: $40.00 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: $290.00 copay Per Trip Air Ambulance: $290.00 copay |
Health Care Services and Medical Supplies
Anthem Medicare Advantage (Regional 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: 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: $50.00 copay - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $130.00 copay Diagnostic Radiological Services: $130.00 copay - $215.00 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: 40% coinsurance |
| Mental Health Inpatient Care | In-Network: Days 1-5: $250.00 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: $40.00 copay Out-of-Network: $60.00 copay |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: 20% coinsurance Observation Services: 20% coinsurance Ambulatory Surgical Center: $235.00 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: $0.00 copay - $40.00 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: 50% coinsurance per stay |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental Services: $0.00 copay This plan covers 1 oral exam(s), 1 cleaning(s) every year. Medicare Covered Dental: $0.00 copay Out-of-Network: Medicare Covered Dental Services: $0.00 copay Preventive Dental: 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 - $40.00 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: $60.00 copay 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: $40.00 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: $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: 40% coinsurance |
Prescription Drug Costs and Coverage
The Anthem Medicare Advantage (Regional PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $50 (excludes Tiers 1, 2 and 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $50 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $50 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $50 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
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