Anthem Medicare Advantage 3 (PPO) - H4036-025-000

4 out of 5 stars* for plan year 2025

$46.00

Monthly Premium

Anthem Medicare Advantage 3 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield

Plan ID: H4036-025-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$46.00

Monthly Premium

Ohio Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Ohio Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$46.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$0.00
Out-of-pocket maximum	$5,900.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$2,000.00
Primary care doctor visit	Out-of-Network: $25.00 copay
Specialty doctor visit	Out-of-Network: $60.00 copay
Inpatient hospital care	Out-of-Network: 40% coinsurance per stay
Urgent care	Urgent Care: $35.00 copay
Emergency room visit	Emergency Care: $125.00 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 per year.
Ambulance transportation	Ground Ambulance: $275.00 copay Per Trip Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem Medicare Advantage 3 (PPO) covers a range of additional benefits. Learn more about Anthem Medicare Advantage 3 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Medicare Covered Chiropractic Services: $60.00 copay
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: 40% coinsurance
Durable medical equipment (DME)	Out-of-Network: 40% coinsurance
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Lab Services: $0.00 copay - $15.00 copay X-Rays: $50.00 copay - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $150.00 copay Diagnostic Radiological Services: $50.00 copay - $295.00 copay
Home health care	Out-of-Network: 40% coinsurance
Mental health inpatient care	In-Network: Days 1-6: $295.00 per day, per admission / Days 7-90: $0.00 per day, per admission
Mental health outpatient care	In-Network: Individual and Group Sessions: $40.00 copay
Outpatient services/surgery	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
Over-the-counter items	This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $100 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts expire at the end of the calendar year.
Podiatry services	Out-of-Network: Medicare Covered Podiatry Services: $60.00 copay Routine Foot Care: $60.00 copay
Skilled Nursing Facility (SNF) care	Out-of-Network: 50% coinsurance per stay

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Dental care	Out-of-Network: Medicare Covered Dental: $0.00 copay Non-Medicare Preventive Dental Services: 20% coinsurance Non-Medicare Comprehensive Dental Services: 50% coinsurance

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

Coverage	Details
Vision care	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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing care	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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Preventive services and health/wellness education programs	Out-of-Network: 40% coinsurance

When reviewing Ohio Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Ohio that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Ohio Counties Served

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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