Anthem Dual Advantage (PPO D-SNP) H4909-018 2024 Plan Details and Costs (2024)

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Anthem Dual Advantage (PPO D-SNP)

Anthem Dual Advantage (PPO D-SNP) H4909-018 Plan Details

3 out of 5 stars

Anthem Dual Advantage (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross and Blue Shield
Plan ID: H4909-018

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Anthem Dual Advantage (PPO D-SNP) H4909-018 Plan Details

3 out of 5 stars

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help

^$0.00

Monthly Premium

Virginia Counties Served

Loudoun Henrico James City Newport News City Chesterfield Roanoke City Portsmouth City Chesapeake City Mecklenburg Richmond City Pittsylvania Campbell Middlesex Danville City Hopewell City Lynchburg City Franklin Galax City Lancaster Madison York Gloucester Halifax Prince Edward Goochland Augusta Hampton City Carroll Hanover Albemarle Scott Norfolk City Suffolk City Stafford Roanoke Virginia Beach City Spotsylvania Petersburg City Colonial Heights City Powhatan Manassas City Fredericksburg City Manassas Park City Falls Church City Harrisonburg City Fauquier Covington City Botetourt Lunenburg Salem Emporia City Williamsburg City Montgomery Floyd Orange Louisa Rappahannock Franklin City King and Queen Alleghany Amherst Waynesboro City Patrick Radford Sussex Prince George Shenandoah King George Southampton Culpeper Essex Poquoson City Appomattox Buckingham Fluvanna Surry Charles City Amelia Rockingham Rockbridge Bland Charlottesville City Craig Bath Bedford Giles Northampton Isle of Wight Greene Greensville Warren Richmond Brunswick Lexington City Page New Kent Caroline Mathews Jefferson Martinsville City Dinwiddie King William Henry Westmoreland Northumberland Nelson Pulaski Buena Vista City Staunton City Highland Nottoway Cumberland Clarke Dickenson Wythe Bristol City Frederick Grayson Russell Norton City Winchester City Washington Wise Smyth Tazewell Lee Buchanan

Basic Costs and Coverage

Coverage	Cost
Monthly Deductible	$0
Out of Pocket Max	In-Network: $8300 Out-of-Network: N/A
Initial Coverage Limit	$5030
Catastrophic Coverage Limit	$8,000
Primary Care Doctor Visit	In-Network: $0.00 copay Out-of-Network: $0.00 copay
Specialty Doctor Visit	In-Network: $0.00 copay Out-of-Network: $0.00 copay
Inpatient Hospital Care	In-Network: $0.00 copay per stay Additional Hospital Days: Unlimited additional days Out-of-Network: $0.00 copay per stay
Urgent Care	Urgent Care: $0.00 copay
Emergency Room Visit	Emergency Care: $0.00 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: $0.00 copay Per Trip Air Ambulance: $0.00 copay

Health Care Services and Medical Supplies

Anthem Dual Advantage (PPO D-SNP) 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: $0.00 copay Out-of-Network: Medicare Covered Chiropractic Services: $0.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring	In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: $0.00 copay
Durable Medical Eqipment (DME)	In-Network: $0.00 copay Out-of-Network: $0.00 copay
Diagnostic Tests, Lab and Radiology Services, and X-Rays	In-Network: Lab Services: $0.00 copay X-Rays: $0.00 copay Therapeutic Radiological Services: $0.00 copay Outpatient Diagnostic Procedures/Tests: $0.00 copay Diagnostic Radiological Services: $0.00 copay Out-of-Network: Lab Services: $0.00 copay X-Rays: $0.00 copay Therapeutic Radiological Services: $0.00 copay Outpatient Diagnostic Procedures/Tests: $0.00 copay Diagnostic Radiological Services: $0.00 copay
Home Health Care	In-Network: $0.00 copay Out-of-Network: $0.00 copay
Mental Health Inpatient Care	In-Network: $0.00 copay per stay Additional Hospital Days: Unlimited additional days Out-of-Network: $0.00 copay per stay
Mental Health Outpatient Care	In-Network: Individual and Group Sessions: $0.00 copay Out-of-Network: $0.00 copay
Outpatient Services / Surgery	In-Network: Outpatient Hospital - Surgery: $0.00 copay Observation Services: $0.00 copay Ambulatory Surgical Center: $0.00 copay Out-of-Network: Outpatient Hospital - Surgery: $0.00 copay Observation Services: $0.00 copay Ambulatory Surgical Center: $0.00 copay
Outpatient Substance Abuse Care	In-Network: Individual and Group Sessions: $0.00 copay Out-of-Network: $0.00 copay
Over-the-counter (OTC) Items	This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $330 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year.
Podiatry Services	In-Network: Medicare Covered Podiatry Services: $0.00 copay Routine Foot Care: $0.00 copay 4 routine foot care visit(s) each year. Out-of-Network: Medicare Covered Podiatry Services: $0.00 copay Routine Foot Care: $0.00 copay
Skilled Nursing Facility Care	In-Network: $0.00 copay per stay Out-of-Network: $0.00 copay per stay

Dental Benefits

The following dental services are covered from in-network providers.

Coverage	Cost
Dental Care	In-Network: Preventive and Comprehensive Dental Combined Allowance This plan covers up to $2,500 for covered preventive and comprehensive dental services every year. Medicare Covered Dental: $0.00 copay Preventive Dental Services: $0.00 copay Comprehensive Dental Services: $0.00 copay Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 40% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00

Coverage

Cost

Dental Care

In-Network:
Preventive and Comprehensive Dental Combined Allowance
This plan covers up to $2,500 for covered preventive and comprehensive dental services every year.

Medicare Covered Dental: $0.00 copay
Preventive Dental Services: $0.00 copay
Comprehensive Dental Services: $0.00 copay

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 40%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00

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 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 Routine Eye Wear: $0.00 copay This plan covers up to $325.00 for eyeglasses or contact lenses every year. Out-of-Network: Medicare Covered Eye Exam: $0.00 copay Routine Eye Exam: $0.00 copay Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay

Coverage

Cost

Vision Benefits

In-Network:
Medicare Covered Eye Exam: $0.00 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
Routine Eye Wear: $0.00 copay
This plan covers up to $325.00 for eyeglasses or contact lenses every year.

Out-of-Network:
Medicare Covered Eye Exam: $0.00 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 from in-network providers.

Coverage	Cost
Hearing Benefits	In-Network: Medicare Covered Hearing Exam: $0.00 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 $3,000.00 maximum plan benefit for prescribed hearing aids every year. Out-of-Network: Medicare Covered Hearing Exam: $0.00 copay Routine Hearing Exam: $0.00 copay for routine hearing exam(s).

Coverage

Cost

Hearing Benefits

In-Network:
Medicare Covered Hearing Exam: $0.00 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 $3,000.00 maximum plan benefit for prescribed hearing aids every year.

Out-of-Network:
Medicare Covered Hearing Exam: $0.00 copay
Routine Hearing Exam: $0.00 copay 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: $0.00 copay

Coverage

Cost

Preventive Services and Health/Wellness Education Programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services

Out-of-Network:
$0.00 copay

Prescription Drug Costs and Coverage

The Anthem Dual Advantage (PPO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

Coverage	Cost
Coverage & Cost
Annual Drug Deductible	$0
Preferred Generic	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Generic	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Preferred Brand	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Non-Preferred Drug	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Specialty Tier	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Select Care Drugs	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Annual Drug Deductible	$0
Preferred Generic	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Generic	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Preferred Brand	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Non-Preferred Drug	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Specialty Tier	Preferred cost-share retail N/A Standard mail order N/A Standard retail N/A
Select Care Drugs	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Annual Drug Deductible	$0
Preferred Generic	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Generic	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Preferred Brand	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Non-Preferred Drug	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00
Specialty Tier	Preferred cost-share retail N/A Standard mail order N/A Standard retail N/A
Select Care Drugs	Preferred cost-share retail $0.00 Standard mail order $0.00 Standard retail $0.00

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