Speak with a licensed insurance agent

1-800-557-6059
|
TTY 711, 24/7

Anthem Grocery (PPO) - H4909-026-000

na* for plan year 2025

$0.00

Monthly Premium

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

Plan ID: H4909-026-000

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

$0.00

Monthly Premium

Virginia 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 Virginia 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

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$295.00
Out-of-pocket maximum$7,950.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:
$35.00 copay
Specialty doctor visit
Out-of-Network:
$60.00 copay
Inpatient hospital careIn-Network:
Days 1-5: $415.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Urgent careUrgent Care: $45.00 copay
Emergency room visitEmergency Care: $110.00 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 transportationGround Ambulance: $305.00 copay Per Trip
Air Ambulance: $305.00 copay

Health Care Services and Medical Supplies

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

CoverageDetails
Chiropractic servicesIn-Network:
Medicare Covered Chiropractic Services: $15.00 copay
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:
35% coinsurance
Durable medical equipment (DME)In-Network:
20% coinsurance
Diagnostic tests, lab and radiology services, and X-raysIn-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 - $140.00 copay
Diagnostic Radiological Services: $50.00 copay - $415.00 copay
Home health care
Out-of-Network:
35% coinsurance
Mental health inpatient careIn-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:
35% coinsurance
Outpatient services/surgeryIn-Network:
Outpatient Hospital - Surgery: $415.00 copay
Observation Services: $415.00 copay
Ambulatory Surgical Center: $365.00 copay
Outpatient substance abuse care
Out-of-Network:
35% coinsurance
Over-the-counter itemsThis plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $60 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts expire at the end of the calendar year.
Podiatry servicesIn-Network:
Medicare Covered Podiatry Services: $45.00 copay
Skilled Nursing Facility (SNF) careIn-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.

CoverageDetails
Dental careThis plan covers up to a $1,000 allowance for covered preventive and comprehensive dental services every year.

In-Network:
Medicare Covered Dental: $0.00 copay
Preventive Dental Services: $0.00 copay
Comprehensive Dental Services: $0.00 copay

Vision Benefits

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

CoverageDetails
Vision care
Out-of-Network:
Medicare Covered Eye Exam: $60.00 copay
Routine Eye Exam: $0.00 copay
Medicare Covered Eye Wear: $60.00 copay

Hearing Benefits

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

CoverageDetails
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.

CoverageDetails
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services

Prescription Drug Costs and Coverage

The Anthem Grocery (PPO) offers prescription drug coverage, with an annual drug deductible of $295.00 (excludes Tiers 1, 2, and 6)

Coverage & Cost
Coverage
Cost
Annual drug deductible$295.00 (excludes Tiers 1, 2, and 6)
Tier 1
  • Preferred retail $0.00
  • Standard retail $5.00
  • Standard mail order $0.00
Tier 2
  • Preferred retail $3.00
  • Standard retail $8.00
  • Standard mail order $0.00
Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual drug deductible$295.00 (excludes Tiers 1, 2, and 6)
Tier 1
  • Preferred retail $0.00
  • Standard retail $10.00
  • Standard mail order $0.00
Tier 2
  • Preferred retail $6.00
  • Standard retail $16.00
  • Standard mail order $0.00
Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00
Annual drug deductible$295.00 (excludes Tiers 1, 2, and 6)
Tier 1
  • Preferred retail $0.00
  • Standard retail $15.00
  • Standard mail order $0.00
Tier 2
  • Preferred retail $9.00
  • Standard retail $24.00
  • Standard mail order $0.00
Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard mail order $0.00

When reviewing Virginia 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 Virginia 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

Virginia Counties Served

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

Back to plans in Virginia

Compare plans today.

Speak with a licensed sales agent

1-800-557-6059
|
TTY 711, 24/7

Every minute we help someone compare their Medicare Advantage plan options.2

Ready to find your plan?

Or call a licensed insurance agent

1-800-557-6059
|
TTY 711, 24/7