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Anthem Medicare Advantage (PPO)

H4036 - 020 - 0
4 out of 5 stars (4 / 5)

Anthem Medicare Advantage (PPO) is a Medicare Advantage Plan by Anthem Blue Cross and Blue Shield.

This page features plan details for 2025 Anthem Medicare Advantage (PPO) H4036 – 020 – 0.

IMPORTANT: This page features the 2025 version of this plan. See the 2025 version using the link below:

Locations

Anthem Medicare Advantage (PPO) is offered in the following locations.

Adams County, Wisconsin
Ashland County, Wisconsin
Barron County, Wisconsin

Click to see more locations

Plan Overview

Anthem Medicare Advantage (PPO) offers the following coverage and cost-sharing.

Insurer:Anthem Blue Cross and Blue Shield
Health Plan Deductible:$0
MOOP:$8,950 In and Out-of-network
$4,700 In-network
Drugs Covered:Yes

Ready to sign up for Anthem Medicare Advantage (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Anthem Medicare Advantage (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Anthem Medicare Advantage (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $195.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $195.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Anthem Medicare Advantage (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Endodontics
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Implant Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Maxillofacial Prosthetics
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Orthodontics
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Periodontics
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Prosthodontics, fixed
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Prosthodontics, removable
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)
  • Restorative Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply, Authorization Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay (Limits Apply)
    • Out-of-Network: 20% Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • In-Network: $0-150 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $50-110 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 20% coinsurance (Authorization Required)
    • In-Network: $50-225 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0-10 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 20% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $35 copay per visit
  • Specialist
    • In-Network: $40 copay per visit (Authorization Required)
  • Primary
    • In-Network: $0 copay
  • Specialist
    • Out-of-Network: $55 copay per visit (Authorization Required)

Emergency care/Urgent care

  • Emergency
    • $90 copay per visit (always covered)
  • Urgent care
    • $30 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • Out-of-Network: $55 copay (Authorization Required)
    • In-Network: $0-40 copay (Authorization Required)
  • Routine foot care
    • In-Network: $0 copay (Authorization Required)

Ground ambulance

    • Out-of-Network: $310 copay
    • In-Network: $310 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • Out-of-Network: $0 copay (Limits Apply, Authorization Required)
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Hearing aids
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Hearing aids OTC
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: $55 copay (Authorization Required)
  • Fitting/evaluation
    • Out-of-Network: 20% coinsurance (Limits Apply, Authorization Required)
  • Hearing aids OTC
    • Out-of-Network: $0 copay (Limits Apply, Authorization Required)

Inpatient hospital coverage

    • In-Network: $370 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • Out-of-Network: $370 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $8,950 In and Out-of-network
      $4,700 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: $0 copay
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 40% coinsurance per item
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: $35 copay or 0-40% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: $35 copay or 0-40% coinsurance (Authorization Required)

Mental health services

  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $60 copay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: $60 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: $60 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: $295 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • In-Network: $295 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: $60 copay (Authorization Required)

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $0-295 copay per visit (Authorization Required)
    • Out-of-Network: 20% coinsurance per visit (Authorization Required)

Preventive care

    • Out-of-Network: 40% coinsurance
    • In-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $60 copay (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: $60 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $40 copay (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 45% per stay (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $203 per day for days 21 through 100 (Authorization Required)

Transportation

    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)

Vision

  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Preventive Dental Package

Diagnostic and Preventive Dental

  • Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Fluoride Treatment
    • Monthly Premium: $25.00

Ready to sign up for Anthem Medicare Advantage (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

For the 2025 version of Anthem Medicare Advantage (PPO)? see 2025 Anthem Medicare Advantage (PPO) at MedicareAdvantageRX.com.

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