Anthem Medicare Advantage (PPO)

Available to residents of Grayson County, VA for 2026. Contract H4909, plan 014, segment 0.

Renewed, service area reduced for 2026. CMS carries this plan forward from 2025.

Plan details

Monthly premium (Part C + D)	$14.00
— medical (Part C) part	$11.30
— drug (Part D) part	$2.70?
Monthly premium with full Extra Help (LIS)	$11.30?drug (Part D) part $0.00; Extra Help does not cover the medical (Part C) premium
Part B premium reduction (giveback)	None
In-network out-of-pocket maximum	$8,950.00?
In- and out-of-network out-of-pocket maximum	$11,300.00
Drug deductible	$250.00Tier 1, 2 and 6 exempt
Drug out-of-pocket threshold	$2,100.00
Plan type	PPO?
Contract / plan	H4909-014-0
Offered by	Anthem Blue Cross and Blue Shield
Parent organization	Elevance Health, Inc.
Formulary drugs	3,554
Formulary exception tier	4?
Pharmacy search	shop.anthem.com/medicare
Member services	(833)668-2249TTY 711

CMS star ratings

Overall: 3.5 out of 5 stars for Overall
Health plan (Part C): 3 out of 5 stars for Health plan (Part C)
Drug plan (Part D): 3.5 out of 5 stars for Drug plan (Part D)

Published per contract — every plan under contract H4909 shares this rating.

Plan health benefits

Service	In-network	Out-of-network?
Doctor visits
Primary care doctor	$0 copay	$35 copay
Specialist	$45 copay(authorization required)	$60 copay
Other health care professional	$0–$15 copay(authorization required)	$35 copay
Additional telehealth services	$0 copay	—
Preventive care
Medicare-covered preventive services	$0 copay	35% coinsurance
Annual physical exam	$0 copay	35% coinsurance
Kidney disease education	$0 copay	35% coinsurance
Glaucoma screening	$0 copay	35% coinsurance
Diabetes self-management training	$0 copay	35% coinsurance
Diagnostic tests, labs and imaging
Diagnostic tests and procedures	$0–$140 copay(authorization required)	35% coinsurance
Lab services	$0–$15 copay(authorization required)	35% coinsurance
Diagnostic radiology (e.g. MRI, CT)	$50–$425 copay(authorization required)	35% coinsurance
Therapeutic radiology	20% coinsurance(authorization required)	35% coinsurance
Outpatient x-rays	$50–$110 copay(authorization required)	35% coinsurance
Emergency and urgent care
Emergency room	$115 copay	—
Urgent care	$40 copay	—
Worldwide emergency coverage	$115 copay · $100,000 plan limit	—
Worldwide urgent care	$115 copay · $100,000 plan limit	—
Worldwide emergency transportation	$115 copay	—
Hospital care
Inpatient hospital stay	$425 per day for days 1–5; $0 per day for days 6–90(authorization required)	35% coinsurance per stay
Outpatient hospital services	$0–$425 copay(authorization required)	35% coinsurance
Outpatient observation	$425 copay(authorization required)	35% coinsurance
Ambulatory surgical center	$0–$375 copay(authorization required)	35% coinsurance
Outpatient blood services	$0 copay	$0 copay
Skilled nursing and home health
Skilled nursing facility	$0 per day for days 1–20; $218 per day for days 21–100(authorization required)	35% coinsurance per stay
Home health care	$0 copay(authorization required)	35% coinsurance
Kidney dialysis	20% coinsurance	20% coinsurance
Rehabilitation
Occupational therapy	$30 copay(authorization required)	35% coinsurance
Physical therapy and speech-language therapy	$30 copay(authorization required)	35% coinsurance
Cardiac rehabilitation	$30 copay(authorization required)	35% coinsurance
Pulmonary rehabilitation	$15 copay(authorization required)	35% coinsurance
Mental health and substance use
Inpatient psychiatric hospital stay	$425 per day for days 1–4; $0 per day for days 5–90(authorization required)	35% coinsurance per stay
Outpatient mental health, individual session	$40 copay(authorization required)	35% coinsurance
Outpatient mental health, group session	$40 copay(authorization required)	35% coinsurance
Psychiatrist, individual session	$40 copay(authorization required)	35% coinsurance
Psychiatrist, group session	$40 copay(authorization required)	35% coinsurance
Partial hospitalization	$40 copay(authorization required)	35% coinsurance
Intensive outpatient program	$40 copay(authorization required)	35% coinsurance
Outpatient substance use, individual session	$40 copay(authorization required)	35% coinsurance
Outpatient substance use, group session	$40 copay(authorization required)	35% coinsurance
Opioid treatment program	$40 copay(authorization required)	35% coinsurance
Ambulance and transportation
Ground ambulance	$350 copay(authorization required)	$350 copay
Air ambulance	$350 copay(authorization required)	$350 copay
Transportation to plan-approved locations	$0 copay(limits apply)	$0 copay
Medical equipment and supplies
Durable medical equipment (e.g. wheelchairs, oxygen)	0%–20% coinsurance(authorization required)	35% coinsurance
Prosthetics (e.g. braces, artificial limbs)	20% coinsurance(authorization required)	35% coinsurance
Medical supplies	20% coinsurance(authorization required)	35% coinsurance
Diabetes supplies	$0 copay	35% coinsurance
Diabetic therapeutic shoes or inserts	$0 copay	35% coinsurance
Chiropractic, acupuncture and foot care
Chiropractic (Medicare-covered)	$15 copay(authorization required)	35% coinsurance
Routine chiropractic care	Not covered	—
Acupuncture	Not covered	—
Foot exams and treatment (Medicare-covered)	$45 copay(authorization required)	$60 copay
Routine foot care	Not covered	—
Dental?
Medicare-covered dental services	$0 copay(authorization required)	$0 copay
Preventive dental plan limit	$1,000 plan limit every year	—
Oral exams	$0 copay(limits apply)	20% coinsurance
Cleanings	$0 copay(limits apply)	20% coinsurance
Fluoride treatment	$0 copay(limits apply)	20% coinsurance
Dental x-rays	$0 copay(limits apply)	20% coinsurance
Other diagnostic dental services	$0 copay(limits apply)	20% coinsurance
Other preventive dental services	$0 copay	20% coinsurance
Restorative services (fillings, crowns)	25% coinsurance(authorization required, limits apply)	50% coinsurance
Endodontics (root canals)	25% coinsurance(authorization required, limits apply)	50% coinsurance
Periodontics (gum disease)	25% coinsurance(authorization required, limits apply)	50% coinsurance
Dentures and other removable prosthodontics	25% coinsurance(authorization required, limits apply)	50% coinsurance
Maxillofacial prosthetics	Not covered	—
Implants	Not covered	—
Bridges and other fixed prosthodontics	25% coinsurance(authorization required, limits apply)	50% coinsurance
Oral and maxillofacial surgery	25% coinsurance(authorization required, limits apply)	50% coinsurance
Orthodontics	Not covered	—
Adjunctive general services	25% coinsurance(authorization required, limits apply)	50% coinsurance
Vision?
Eye exam (Medicare-covered)	$0–$45 copay(limits apply)	$60 copay
Routine eye exam	$0 copay(limits apply)	$0 copay
Eyewear after cataract surgery (Medicare-covered)	$0 copay(limits apply)	$60 copay
Eyewear plan limit	$125 plan limit every year	—
Contact lenses	$0 copay(limits apply)	$0 copay
Eyeglasses (frames and lenses)	$0 copay(limits apply)	$0 copay
Eyeglass lenses	$0 copay(limits apply)	$0 copay
Eyeglass frames	$0 copay(limits apply)	$0 copay
Eyewear upgrades	Not covered	—
Hearing?
Hearing exam (Medicare-covered)	$45 copay(authorization required, limits apply)	$60 copay
Routine hearing exam	$0 copay(authorization required, limits apply)	20% coinsurance
Hearing aid fitting and evaluation	$0 copay(authorization required, limits apply)	20% coinsurance
Hearing aid plan limit	$1,000 plan limit every year	—
Hearing aids (all types)	$0 copay(authorization required, limits apply)	$0 copay
Hearing aids, inner ear	Not covered	—
Hearing aids, outer ear	Not covered	—
Hearing aids, over the ear	Not covered	—
Medicare Part B drugs
Part B insulin	$35 copay(authorization required, step therapy may apply)	$35 copay
Chemotherapy and radiation drugs	0%–20% coinsurance(authorization required, step therapy may apply)	0%–35% coinsurance
Other Part B drugs	0%–20% coinsurance(authorization required, step therapy may apply)	0%–35% coinsurance
Other extra benefits?
Over-the-counter (OTC) allowance	Not covered	—
Meals after a hospital stay or for a chronic condition	Not covered	—
Fitness benefit	Not covered	—
Health education	Not covered	—
Nutritional / dietary benefit	Not covered	—
Extra smoking and tobacco cessation counseling	Not covered	—
Enhanced disease management	Not covered	—
Telemonitoring	Not covered	—
Remote access technologies (web/phone, nurse line)	$0 copay(limits apply)	$0 copay
Home and bathroom safety devices	$0 copay(limits apply)	$0 copay
Counseling services	Not covered	—
In-home safety assessment	Not covered	—
Personal emergency response system (PERS)	Not covered	—
Medical nutrition therapy	Not covered	—
Post-discharge in-home medication reconciliation	Not covered	—
Re-admission prevention	Not covered	—
Wigs for hair loss from chemotherapy	Not covered	—
Weight management programs	Not covered	—
Alternative therapies	Not covered	—
Therapeutic massage	Not covered	—
Adult day health services	Not covered	—
Home-based palliative care	Not covered	—
In-home support services	Not covered	—
Support for caregivers	Not covered	—

In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.

Drug tiers — preferred pharmacy, initial coverage

Tier	Cost-sharing
Tier 1	$0.00
Tier 2	$0.00
Tier 3	25%
Tier 4	30%
Tier 5	30%
Tier 6	$0.00

Rx cost-sharing by coverage phase

Tier	30-day supply			90-day supply
Tier	Preferred	Standard	Mail Order	Preferred	Standard	Mail Order
Initial deductible phase
Tier 1: Preferred Generic	$0.00	$5.00	$0.00	$0.00	$15.00	$0.00
Tier 2: Generic	$0.00	$10.00	$0.00	$0.00	$30.00	$0.00
Tier 6: Select Care Drugs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Initial coverage phase
Tier 1: Preferred Generic	$0.00	$5.00	$0.00	$0.00	$15.00	$0.00
Tier 2: Generic	$0.00	$10.00	$0.00	$0.00	$30.00	$0.00
Tier 3: Preferred Brand	25%	25%	25%	25%	25%	25%
Tier 4: Non-Preferred Drug	30%	30%	30%	30%	30%	30%
Tier 5: Specialty Tier	30%	30%	30%	n/a	n/a	n/a
Tier 6: Select Care Drugs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Catastrophic coverage phase
Tier 1: Preferred Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 2: Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 3: Preferred Brand	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 4: Non-Preferred Drug	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 5: Specialty Tier	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 6: Select Care Drugs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

Benefits in plain text

Anthem Medicare Advantage (PPO) (H4909-014-0) is a 2026 PPO Medicare Advantage plan offered by Anthem Blue Cross and Blue Shield, available to residents of Grayson County, VA.

The monthly premium is $14.00 (Part C and Part D together).

With full Extra Help (the Low-Income Subsidy), the total monthly premium is $11.30.

Its in-network out-of-pocket maximum is $8,950.00.

The combined in- and out-of-network out-of-pocket maximum is $11,300.00.

The drug deductible is $250.00. Tier 1, 2 and 6 exempt.

The plan's formulary lists 3,554 drugs.

At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: 25%; tier 4: 30%; tier 5: 30%; tier 6: $0.00.

CMS gives the plan's contract (H4909) an overall rating of 3.5 out of 5 stars.

Email a copy of the plan benefit details

Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.