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Anthem Medicare Advantage 3 (PPO)

H4036 - 008 - 0
4 out of 5 stars (4 / 5)

Anthem Medicare Advantage 3 (PPO) is a Medicare Advantage Plan by Anthem Blue Cross and Blue Shield.

This page features plan details for 2025 Anthem Medicare Advantage 3 (PPO) H4036 – 008 – 0 available in Select Counties in Wisconsin.

Locations

Anthem Medicare Advantage 3 (PPO) is offered in the following locations.

Adams County, Wisconsin
Ashland County, Wisconsin
Bayfield County, Wisconsin

Click to see more locations

Plan Overview

Anthem Medicare Advantage 3 (PPO) offers the following coverage and cost-sharing.

Insurer:Anthem Blue Cross and Blue Shield
Health Plan Deductible:$0
MOOP:$8,950 In and Out-of-network
$4,500 In-network
Drugs Covered:Yes

Ready to sign up for Anthem Medicare Advantage 3 (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Anthem Medicare Advantage 3 (PPO) has a monthly premium of $39.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $39.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Anthem Medicare Advantage 3 (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $120.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$39.00$0.00

Initial Coverage Phase

After you pay your $120.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Anthem Medicare Advantage 3 (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay
    • Out-of-Network: 20% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $50-225 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-150 copay (Authorization Required)
    • Out-of-Network: 35% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $50-110 copay (Authorization Required)
  • Lab services
    • In-Network: $0-10 copay (Authorization Required)
    • Out-of-Network: 35% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 35% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 35% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $5 copay per visit
  • Specialist
    • In-Network: $40 copay per visit (Authorization Required)
    • Out-of-Network: $60 copay per visit (Authorization Required)
  • Primary
    • Out-of-Network: $40 copay per visit

Emergency care/Urgent care

  • Emergency
    • $90 copay per visit (always covered)
  • Urgent care
    • $35 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $0-40 copay (Authorization Required)
    • Out-of-Network: $60 copay (Authorization Required)
  • Routine foot care
    • In-Network: $0 copay (Authorization Required)

Ground ambulance

    • Out-of-Network: $295 copay
    • In-Network: $295 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply, Authorization Required)
    • Out-of-Network: 20% coinsurance (Limits Apply, Authorization Required)
  • Hearing aids OTC
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $60 copay (Authorization Required)
  • Hearing aids
    • In-Network: $0 copay (Limits Apply, Authorization Required)
    • Out-of-Network: $0 copay (Limits Apply, Authorization Required)
  • Hearing aids OTC
    • Out-of-Network: $0 copay (Limits Apply, Authorization Required)
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay (Authorization Required)

Inpatient hospital coverage

    • Out-of-Network: 40% per stay (Authorization Required)
    • In-Network: $295 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $8,950 In and Out-of-network
      $4,500 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: $0 copay
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 40% coinsurance per item

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: $35 copay or 0-40% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: $35 copay or 0-40% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: $60 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $250 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: $60 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: 40% per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $60 copay (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: $60 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $0 copay or 20% coinsurance per visit (Authorization Required)
    • Out-of-Network: 40% coinsurance per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: 40% coinsurance

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: $60 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $35 copay (Authorization Required)
    • Out-of-Network: $60 copay (Authorization Required)
  • Occupational therapy visit
    • In-Network: $35 copay (Authorization Required)

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $203 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 45% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • Not covered
  • Eyeglass frames
    • Not covered
  • Other
    • Not covered
  • Upgrades
    • Not covered
  • Eyeglasses (frames and lenses)
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Preventive Dental Package

Diagnostic and Preventive Dental

  • Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Fluoride Treatment
    • Monthly Premium: $25.00

Ready to sign up for Anthem Medicare Advantage 3 (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Table of Contents

Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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