Anthem I MaineHealth Advantage Access (PPO)

Anthem I MaineHealth Advantage Access (PPO) H9219-001 Plan Details
3.5 out of 5 stars

Anthem I MaineHealth Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem I MaineHealth
Plan ID: H9219-001

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.

$20.00
Monthly Premium

Anthem I MaineHealth Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem I MaineHealth
Plan ID: H9219-001

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 I MaineHealth Advantage Access (PPO) H9219-001 Plan Details
3.5 out of 5 stars

Anthem I MaineHealth Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Anthem I MaineHealth
Plan ID: H9219-001

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.

$20.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $400
Out of Pocket Max In-Network: $6350
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:
40% coinsurance
Specialty Doctor Visit
In-Network:
$45.00 copay
Out-of-Network:
40% coinsurance
Inpatient Hospital Care
In-Network:
Days 1-7: $325.00 per day, per admission / Days 8-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
40% coinsurance per stay
Urgent Care
Urgent Care: $35.00 copay
Emergency Room Visit
Emergency Care: $90.00 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: $295.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Anthem I MaineHealth Advantage Access (PPO) 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: $20.00 copay
Out-of-Network:
Medicare Covered Chiropractic Services: 40% coinsurance
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Out-of-Network:
40% coinsurance
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Out-of-Network:
40% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay - $10.00 copay
X-Rays: $20.00 copay - $40.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay - $80.00 copay
Diagnostic Radiological Services: $100.00 copay - $200.00 copay
Out-of-Network:
Lab Services: 40% coinsurance
X-Rays: 40% coinsurance
Therapeutic Radiological Services: 40% coinsurance
Outpatient Diagnostic Procedures/Tests: 40% coinsurance
Diagnostic Radiological Services: 40% coinsurance
Home Health Care
In-Network:
$0.00 copay
Out-of-Network:
40% coinsurance
Mental Health Inpatient Care
In-Network:
Days 1-6: $325.00 per day, per admission / Days 7-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Out-of-Network:
40% coinsurance per stay
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $40.00 copay
Out-of-Network:
40% coinsurance
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $325.00 copay
Observation Services: $325.00 copay
Ambulatory Surgical Center: $325.00 copay
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
Out-of-Network:
40% coinsurance
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $45.00 copay
Out-of-Network:
Medicare Covered Podiatry Services: 40% coinsurance
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day
Out-of-Network:
40% coinsurance 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 $1,000 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:
Copayment for Medicare Covered Comprehensive Dental $0.00
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 - $45.00 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 $150.00 for eyeglasses or contact lenses every year.
Out-of-Network:
Medicare Covered Eye Exam: 40% coinsurance
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: $45.00 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 $2,000.00 maximum plan benefit for prescribed hearing aids every year.
Out-of-Network:
Medicare Covered Hearing Exam: 40% coinsurance
Routine Hearing Exam: 20% coinsurance 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:
40% coinsurance

Prescription Drug Costs and Coverage

The Anthem I MaineHealth Advantage Access (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $400 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $400 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $3.00
  • Standard retail $8.00
  • Standard mail order $0.00
Generic
  • Preferred cost-share retail $10.00
  • Standard retail $15.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $400 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $6.00
  • Standard retail $16.00
  • Standard mail order $0.00
Generic
  • Preferred cost-share retail $20.00
  • Standard retail $30.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $400 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred cost-share retail $9.00
  • Standard retail $24.00
  • Standard mail order $0.00
Generic
  • Preferred cost-share retail $30.00
  • Standard retail $45.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00