Anthem Dual Advantage (PPO D-SNP)
Anthem Dual Advantage (PPO D-SNP) H4704-001 Plan Details
Anthem Dual Advantage (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross Life and Health Insurance Company
Plan ID: H4704-001
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$32.70
Monthly Premium
Anthem Dual Advantage (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross Life and Health Insurance Company
Plan ID: H4704-001
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Anthem Dual Advantage (PPO D-SNP) H4704-001 Plan Details
Anthem Dual Advantage (PPO D-SNP) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem Blue Cross Life and Health Insurance Company
Plan ID: H4704-001
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$32.70
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $8850 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: Days 1-5: $0.00 - $275.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: Days 1-5: $0.00 - 275.00 per day, per admission / Days 6-90: $0.00 per day, per admission |
| Urgent Care | Urgent Care: $0.00 copay - $55.00 copay |
| Emergency Room Visit | Emergency Care: $0.00 copay -$90.00 copay Copay waived if admitted to hospital within 24 hours 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 - 20% coinsurance Per Trip Air Ambulance: $0.00 copay - 20% coinsurance |
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 - 20% coinsurance Out-of-Network: Medicare Covered Chiropractic Services: $0.00 copay - 20% coinsurance |
| 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 - 20% coinsurance Out-of-Network: $0.00 copay - 20% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay - 20% coinsurance X-Rays: $0.00 copay - 20% coinsurance Therapeutic Radiological Services: $0.00 copay - 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - 20% coinsurance Diagnostic Radiological Services: $0.00 copay - 20% coinsurance Out-of-Network: Lab Services: $0.00 copay - 20% coinsurance X-Rays: $0.00 copay - 20% coinsurance Therapeutic Radiological Services: $0.00 copay - 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - 20% coinsurance Diagnostic Radiological Services: $0.00 copay - 20% coinsurance |
| Home Health Care | In-Network: $0.00 copay Out-of-Network: $0.00 copay - 20% coinsurance |
| Mental Health Inpatient Care | In-Network: Days 1-5: $0.00 - $275.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: Days 1-5: $0.00 - 275.00 per day, per admission / Days 6-90: $0.00 per day, per admission |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $0.00 copay - 20% coinsurance Out-of-Network: $0.00 copay - 20% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $0.00 copay - 20% coinsurance Observation Services: $0.00 copay - 20% coinsurance Ambulatory Surgical Center: $0.00 copay - 20% coinsurance Out-of-Network: Outpatient Hospital - Surgery: $0.00 copay - 20% coinsurance Observation Services: $0.00 copay - 20% coinsurance Ambulatory Surgical Center: $0.00 copay - 20% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $0.00 copay - 20% coinsurance Out-of-Network: $0.00 copay - 20% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $80 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 - 20% coinsurance Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. Out-of-Network: Medicare Covered Podiatry Services: $0.00 copay - 20% coinsurance Routine Foot Care: $0.00 copay |
| Skilled Nursing Facility Care | In-Network: Days 1 - 20: $0.00 per day / Days 21 - 100: $0.00 - $196.00 per day Out-of-Network: Days 1 - 20: $0.00 per day / Days 21 - 100: $0.00 - $196.00 per day |
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 $2,600 for covered preventive and comprehensive dental services every year. Medicare Covered Dental: $0.00 copay - 20% coinsurance 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 20% 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 - 20% coinsurance 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 - 20% coinsurance Routine Eye Wear: $0.00 copay This plan covers up to $150.00 for eyeglasses or contact lenses every year. Out-of-Network: Medicare Covered Eye Exam: $0.00 copay - 20% coinsurance Routine Eye Exam: $0.00 copay Medicare Covered Eye Wear: $0.00 copay - 20% coinsurance 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 - 20% coinsurance 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 - 20% coinsurance 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 - 20% coinsurance |
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 |
|
| Generic |
|
| Preferred Brand |
|
| Non-Preferred Drug |
|
| Specialty Tier |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $0 |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Non-Preferred Drug |
|
| Specialty Tier |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $0 |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Non-Preferred Drug |
|
| Specialty Tier |
|
| Select Care Drugs |
|
