Anthem PPO
Medicare Advantage PPO including Rx Coverage
This Anthem PPO plan allows you to use any doctor, hospital, or medical provider that accepts Medicare. Over 93% of all doctors accept Medicare. This plan is good in all 50 states and the District of Columbia. Some coverage is available worldwide while traveling.
Unlike HMO-style plans, you may go to any doctor, specialist, or hospital without a referral. The provider does not need to be part of the Anthem network. The only requirement is that they accept Medicare.
2025 Annual Notice of Change Updates
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Annual |
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| Annual Out-of-Pocket Maximum – Medical |
$3,400 |
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| Annual Out-of-Pocket Maximum – Rx |
$2,000 |
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Physician Services |
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| Primary Care Physician and Specialists |
$0 |
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Annual Physical Exams |
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| Wellness Exam (Medicare Exam) and Routine Physical Exam |
$0 |
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Inpatient Services |
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| Inpatient Stay including Hospital and Mental HealthSkilled Nursing Facility CareBlood including Storage and Administration |
$0 |
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Outpatient Services |
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| Office Visits and Telehealth office visitsSpecialist Consultation, Diagnosis, and TreatmentRetail health clinics
Basic diagnostic hearing and balance exams Second opinion prior to surgery Physician services rendered in the home Outpatient services including hospital, mental health care, and substance abuse |
$0 |
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Prescription Drugs |
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30 Day Supply for Retail |
Preferred Network Pharmacy* |
Standard Network Pharmacy |
Mail Order Pharmacy |
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| Select GenericGenericPreferred Brand
Non-Preferred Brand & Non-Formulary Specialty |
$0 $10 $20 $35 $35 |
$0 $20 $30 $45 $45 |
$0 $20 $40 $70 $70 |
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Catastrophic Coverage Select Generic Generic Brand Name |
$0 Greater of $3.70 copay or 5% Greater of $9.20 copay or 5% |
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| Part B Drugs – Immunosuppresses, anti-nausea, inhalation solutions, outpatient injectables, and chemotherapy drugs |
20% |
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Extra Covered Drugs |
Preferred Network Pharmacy* |
Standard Network Pharmacy |
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| Cough and ColdDrug Efficacy Study Implementation (DESI)Vitamins and Minerals
Lifestyle Drugs, including Erectile Dysfunction (ED) |
See Formulary for complete list of drugs covered |
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| Generics / Preferred Brands / Non-Preferred Brands |
You pay your Preferred Retail or Mail-Order copay |
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| Note: Extra Covered Drugs are covered drugs that are often excluded from Part D coverage. Some of these drugs may be required on your drug plan by state regulations. These drugs do not count towards your True Out of Pocket expenses. They do not qualify for lower Catastrophic copays. If you have a deductible, it does not apply to these drugs. These drugs are covered by your Senior Rx Plus benefits. | |||||
| *This plan uses the IngenioRx network of preferred pharmacies. There are over 70,000 pharmacies in the network and include Walmart, Kroger, CVS Pharmacy, more than 5,000 Health Mart Atlas pharmacies, and many independent pharmacies. | |||||
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Preventative Services (Medicare Covered) |
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| Bone Mass MeasurementsColorectal Screening ExamsMammograms
Pap Smears and Pelvic Exams Prostate Cancer Screening Exams Cardiovascular Screenings Smoking Cessation Visit Abdominal Aortic Aneurysm (AAA) Screening Diabetes Screening HIV Screening Screening and Behavioral Counseling to Reduce Alcohol Misuse Depression Screening Screening for Sexually Transmitted Infections Screening and Counseling for Obesity Diabetes – Self-Management Training Medical Nutrition Therapy and Counseling Glaucoma Screening Kidney Disease Education |
$0 |
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Immunizations |
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| Flu, Pneumonia, Hepatitis B, & Other Vaccines if at risk and meet Medicare rules |
$0 |
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Podiatry Services |
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| Treatment of injuries and disease of the feetFoot care with conditions affecting lower limbsExam for people with diabetic peripheral |
$0 |
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Emergency / Urgently Care / Ambulance Services |
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| Ambulance Services |
$50 |
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| Emergency Room |
$50 |
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| Urgently Needed Care (Medicare Covered) |
$0 |
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Home Healthcare Agency |
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| Home Care VisitsHospice (Medicare Covered) |
$0 |
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Durable Medical Equipment |
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| Durable Medical Equipment, Diabetes Monitoring Supplies, and Medical SuppliesProsthetics |
10% |
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Other Wellness Services |
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| Vision Care for Injury or Diagnosis of DiseaseSilver Sneakers Gym AccessNurse HelpLine
Routing Foot Care Video Doctor Visits Healthy Food Deliveries |
$0 |
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| AcupunctureChiropractic Services |
$10 |
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Hearing |
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| ExamHearing Aid Allowance |
$0 $500 |
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Foreign Travel |
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| Emergency Outpatient Care |
$50 |
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| Urgently Needed Services |
$0 |
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| Emergency Inpatient Care |
$0 |
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| Emergency or urgently needed care services while traveling outside the United States or its territories during a temporary absence of less than six months. Outpatient copay is waived if member is admitted to hospital within 72 hours for the same condition.This coverage is worldwide and is limited to what is allowed under the Medicare fee schedule for the services performed/received in the United States. | |||||
The above is a summary of plan benefits and not a comprehensive list. While believed accurate, nothing listed above can change or alter the Certificate of Insurance.