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Anthem Medicare Advantage (PPO) - H4036-028-000
$48.00
Monthly Premium
Anthem Medicare Advantage (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4036-028-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$48.00
Monthly Premium
New Hampshire 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 New Hampshire Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $48.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $395.00 |
| Out-of-pocket maximum | $8,000.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: $10.00 copay |
| Specialty doctor visit | In-Network: $35.00 copay |
| Inpatient hospital care | In-Network: Days 1-4: $415.00 per day, per admission / Days 5-90: $0.00 per day, per admission |
| Urgent care | Urgent Care: $45.00 copay |
| Emergency room visit | Emergency Care: $110.00 copay |
| Ambulance transportation | Ground Ambulance: $300.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Anthem Medicare Advantage (PPO) covers a range of additional benefits. Learn more about Anthem Medicare Advantage (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Medicare Covered Chiropractic Services: $15.00 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: $65.00 copay - $85.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $85.00 copay Diagnostic Radiological Services: $65.00 copay - $250.00 copay |
| Home health care | In-Network: $0.00 copay |
| Mental health inpatient care | In-Network: Days 1-4: $415.00 per day, per admission / Days 5-90: $0.00 per day, per admission |
| Mental health outpatient care | Out-of-Network: $65.00 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 $70 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: $65.00 copay |
| Skilled Nursing Facility (SNF) care | In-Network: Days 1 - 20: $0.00 per day / Days 21 - 100: $214.00 per day |
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 | In-Network: Medicare Covered Eye Exam: $0.00 copay - $35.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. $69 maximum eye exam coverage amount. Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $125 for eyeglasses or contact lenses every year. |
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: $65.00 copay |
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 |
Prescription Drug Costs and Coverage
The Anthem Medicare Advantage (PPO) offers prescription drug coverage, with an annual drug deductible of $395.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $395.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
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| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $395.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $395.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
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| Tier 2 |
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| Tier 6 |
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When reviewing New Hampshire 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 New Hampshire 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 |
New Hampshire Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.