Anthem Medicare Advantage (PPO)
Available to residents of Wythe County, VA for 2027. Contract H4909, plan 014, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Wythe County
- Plan website
- Browse the Anthem Medicare Advantage (PPO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed for 2027. CMS carries this plan forward from 2026. Every VA plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $30.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $30.00? |
| Monthly premium with full Extra Help (LIS) | $23.70? |
| 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 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO? |
| Contract / plan | H4909-014-0 |
| Offered by | Anthem Blue Cross and Blue Shield |
| Parent organization | Elevance Health, Inc. |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | shop.anthem.com/medicare |
| Member services | (833)668-2249TTY 711 |
CMS star ratings
- Overall
- 3 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 | $345 copay(authorization required) | $345 copay |
| Air ambulance | $345 copay(authorization required) | $345 copay |
| Transportation to plan-approved locations | $0 copay(limits apply) | 80% coinsurance |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 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(authorization required) | 35% coinsurance |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) | 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) | 80% coinsurance |
| 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, CY2027). 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 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $0.00 |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 28% |
| Tier 5 · Specialty Tier | 30% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial 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 | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 28% | 28% | 28% | 28% | 28% | 28% |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 2 out of 5 stars for Breast Cancer Screening | 2 out of 5 stars for Breast Cancer Screening |
| Colorectal Cancer Screening · C02 | 2 out of 5 stars for Colorectal Cancer Screening | 3 out of 5 stars for Colorectal Cancer Screening |
| Annual Flu Vaccine · C03 | 4 out of 5 stars for Annual Flu Vaccine | 3 out of 5 stars for Annual Flu Vaccine |
| Improving or Maintaining Physical Health · C04 | 3 out of 5 stars for Improving or Maintaining Physical Health | 2 out of 5 stars for Improving or Maintaining Physical Health |
| Improving or Maintaining Mental Health · C05 | 3 out of 5 stars for Improving or Maintaining Mental Health | 1 out of 5 stars for Improving or Maintaining Mental Health |
| Monitoring Physical Activity · C06 | 1 out of 5 stars for Monitoring Physical Activity | 3 out of 5 stars for Monitoring Physical Activity |
| Managing Chronic (Long Term) Conditions | ||
| Care for Older Adults – Medication Review · C08 | 5 out of 5 stars for Care for Older Adults – Medication Review | not required |
| Care for Older Adults - Functional Status Assessment · C09 | 2 out of 5 stars for Care for Older Adults - Functional Status Assessment | new measure |
| Osteoporosis Management in Women who had a Fracture · C10 | 1 out of 5 stars for Osteoporosis Management in Women who had a Fracture | 2 out of 5 stars for Osteoporosis Management in Women who had a Fracture |
| Diabetes Care – Eye Exam · C11 | 2 out of 5 stars for Diabetes Care – Eye Exam | 3 out of 5 stars for Diabetes Care – Eye Exam |
| Diabetes Care – Blood Sugar Controlled · C12 | 2 out of 5 stars for Diabetes Care – Blood Sugar Controlled | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 2 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | 3 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes |
| Controlling High Blood Pressure · C14 | 2 out of 5 stars for Controlling High Blood Pressure | 3 out of 5 stars for Controlling High Blood Pressure |
| Reducing the Risk of Falling · C15 | 2 out of 5 stars for Reducing the Risk of Falling | 2 out of 5 stars for Reducing the Risk of Falling |
| Improving Bladder Control · C16 | 2 out of 5 stars for Improving Bladder Control | 3 out of 5 stars for Improving Bladder Control |
| Plan All-Cause Readmissions · C17 | 4 out of 5 stars for Plan All-Cause Readmissions | 4 out of 5 stars for Plan All-Cause Readmissions |
| Statin Therapy for Patients with Cardiovascular Disease · C18 | 2 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease | 1 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease |
| Transitions of Care · C19 | 4 out of 5 stars for Transitions of Care | 4 out of 5 stars for Transitions of Care |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 2 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 2 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 2 out of 5 stars for Getting Needed Care | 3 out of 5 stars for Getting Needed Care |
| Customer Service · C23 | 4 out of 5 stars for Customer Service | not enough data |
| Rating of Health Care Quality · C24 | 3 out of 5 stars for Rating of Health Care Quality | 3 out of 5 stars for Rating of Health Care Quality |
| Rating of Health Plan · C25 | 3 out of 5 stars for Rating of Health Plan | 2 out of 5 stars for Rating of Health Plan |
| Care Coordination · C26 | not enough data | 4 out of 5 stars for Care Coordination |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 4 out of 5 stars for Complaints about the Health Plan | 4 out of 5 stars for Complaints about the Health Plan |
| Members Choosing to Leave the Plan · C28 | 4 out of 5 stars for Members Choosing to Leave the Plan | 3 out of 5 stars for Members Choosing to Leave the Plan |
| Health Plan Quality Improvement · C29 | not enough data | 3 out of 5 stars for Health Plan Quality Improvement |
| Health Plan Customer Service | ||
| Plan Makes Timely Decisions about Appeals · C30 | 4 out of 5 stars for Plan Makes Timely Decisions about Appeals | 3 out of 5 stars for Plan Makes Timely Decisions about Appeals |
| Reviewing Appeals Decisions · C31 | 3 out of 5 stars for Reviewing Appeals Decisions | 5 out of 5 stars for Reviewing Appeals Decisions |
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 4 out of 5 stars for Complaints about the Drug Plan | 4 out of 5 stars for Complaints about the Drug Plan |
| Members Choosing to Leave the Plan · D03 | 4 out of 5 stars for Members Choosing to Leave the Plan | 3 out of 5 stars for Members Choosing to Leave the Plan |
| Drug Plan Quality Improvement · D04 | not enough data | 5 out of 5 stars for Drug Plan Quality Improvement |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 3 out of 5 stars for Rating of Drug Plan | 3 out of 5 stars for Rating of Drug Plan |
| Getting Needed Prescription Drugs · D06 | not enough data | 3 out of 5 stars for Getting Needed Prescription Drugs |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 4 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 2 out of 5 stars for Medication Adherence for Diabetes Medications | 3 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 3 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 3 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 2 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 2 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 4 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 4 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H4909 shares it.
Also available in 93 other VA counties
- Alleghany
- Amelia
- Amherst
- Appomattox
- Augusta
- Bedford
- Bland
- Botetourt
- Brunswick
- Buchanan
- Buckingham
- Buena Vista City
- Campbell
- Caroline
- Carroll
- Charlotte
- Charlottesville City
- Chesapeake City
- Chesterfield
- Clarke
- Covington City
- Danville City
- Dickenson
- Dinwiddie
- Emporia City
- Essex
- Falls Church City
- Floyd
- Fluvanna
- Franklin City
- Franklin
- Frederick
- Galax City
- Goochland
- Grayson
- Greene
- Greensville
- Halifax
- Henry
- Highland
- Isle of Wight
- James City
- King and Queen
- King George
- Lancaster
- Lee
- Lexington City
- Louisa
- Lunenburg
- Lynchburg City
- Madison
- Manassas City
- Mathews
- Mecklenburg
- Middlesex
- Montgomery
- Nelson
- Norfolk City
- Northampton
- Norton City
Benefits in plain text
Anthem Medicare Advantage (PPO) (H4909-014-0) is a 2027 PPO Medicare Advantage plan offered by Anthem Blue Cross and Blue Shield, available to residents of Wythe County, VA.
The monthly premium is $30.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $23.70.
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 and 2 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $0.00; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 28%; tier 5 (Specialty Tier): 30%.
CMS gives the plan's contract (H4909) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.