Anthem Medicare Preferred Standard for Dodge, WI

Anthem Medicare Preferred Standard
Summary Rating:This Medicare drug plan has an average rating of 3.0
Part C Premium:
Part D Deductible:$176.00
Mail Order:No
Gap Coverage:No Gap Coverage
Formulary Drugs:2880
Plan ID:H4036-005
Plan Year:2014
Residents of:WI Residents
Plan Type:Local PPO
Summary of Benefits:

Medicare Advantage Plan Summary & Benefits

Anthem Medicare Preferred Standard, WI Medicare Advantage PlanAnthem Medicare Preferred Standard (H4036-005), Preferred Provider Organization Advantage Plan, Dodge County, WI

Anthem Medicare Preferred Standard is a Preferred Provider Organization (PPO) healthcare plan for seniors and other beneficiaries in Dodge County, WI with Medicare benefits. A Medicare Advantage PPO plan gives you freedom to choose which doctors, specialists, and hospitals you visit. You can lower your costs when you use network providers. Plus, predictable copayments and coinsurance make it easier for you to budget healthcare costs.

The plan information presented on this page is a summary, but not a complete description of available benefits. Comprehensive information about the plan benefits is available from your agent.

Summary of Benefits

When this page was published the Summary of Benefits document for this 2014 health plan was not available. Please Ask an Agent for the Summary of Benefits documentation before choosing this plan.

Monthly Premium

The monthly premium for this health insurance plan in Dodge County is $62.00 plus your monthly Medicare Part B premium. Most Medicare beneficiaries pay the standard monthly Part B premium in addition to their MA or MAPD plan premium. However, some beneficiaries are required to pay slightly higher Part B and Medicare Part D premiums because of their income (over $85,000 per year for singles or $170,000 for married couples), or due to late enrollment penalties.

Part D Prescription Drug Plan Information

This plan includes prescription drug coverage. The formulary (00014280) has a total of 2,880 prescription medications.

If you have Part D assistance, your premium will be adjusted based on your percentage.

Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Drugs per Tier:360854640257390
  — Cost-Sharing in ICP:$4.00$15.00$35.00$85.0033%

The Medicare Part D deductible with this health plan is $176.00. This is the amount you will pay until the plan begins to pay its portion.

Maximum Out of Pocket (MOOP) Benefit

The new healthcare law allows for a maximum limit of $6,700 on your out of pocket medical costs for 2014 Medicare Advantage plans. This amount is commonly called the plan MOOP (Maximum Out of Pocket). A plan's MOOP does not include your prescription drugs or the monthly premiums you pay for your health plan. Although the mandatory MOOP limit is $6,700, the Affordable Care Act law allows for a “Voluntary MOOP” that can be as low as $3,400. The MOOP on this plan is $4,200 .

Doctor Visits

Most Medicare health plans require you to make a co-payment (aka, copay) when you visit your primary care physician or a doctor. Here's how this plan works:

  • $5 co-payment for each visit to your primary care physician.
  • $30 co-payment for each visit to a specialist covered by Medicare.
  • $10 co-payment for each visit to your primary care physician.
  • $50 co-payment for each visit to a specialist covered by Medicare.

Urgent Care Doctor Visits

Urgent care is the delivery of ambulatory medical care outside of a hospital emergency department on a walk-in basis without a scheduled appointment. Here's how Urgent Care works with this plan:

  • $45 co-payment for urgent care treatment covered by Medicare.

Emergency Care

Emergency care is medical attention for patients with acute illnesses or injuries which require immediate medical attention. Here's how Emergency Care works with this plan:

  • $65 co-payment for emergency room treatments covered by Medicare.
  • Worldwide coverage.

Ambulance Service

Most health plans do not cover transportation to and from medical services. The exception, of course, is when you have an emergency or when non-ambulatory. Here's how this plan covers ambulance service:

  • Pre-authorization rules apply.
  • $150 co-payment for ambulance benefits covered by Medicare.
  • $150 co-payment for ambulance benefits covered by Medicare.

Inpatient Treatment (Hospital Stays)

A patient who is admitted to a hospital or clinic for treatment that requires at least one overnight stay is an inpatient. Most health plans have a tiered cost structure for inpatient treatment. Here's how this plan covers hospital stays:

  • There is no limit to the number of days covered by the plan per stay in the hospital.
  • For hospital stay covered by Medicares:
  • Days 1 - 7: $200 co-payment per day.
  • .
  • Days 8 - 90: $0 co-payment per day.
  • $0 co-payment for additional non-Medicare-covered hospital days.
  • Except in the case of an emergency your physician must let the plan know when you are to be admitted into the hospital.
  • 30% of the cost for each hospital stay covered by Medicare.
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    This page was last updated on: 10/28/2013

    More Information

    About The Insurer Anthem Blue Cross and Blue Shield

    Anthem was an insurance company which began in the 1980s then merged in 2004 with the Blue Cross Blue Shield organizations of several states, then merged again in late 2004 with WellPoint. The combined company took the WellPoint name. While Anthem no longer exists as a company, the Anthem Blue Cross and Blue Shield brand name is used by WellPoint in 11 states.

    The summary (overall) rating for this plan is 3.0 out of 5 based on reviews from 0 user ratings from the previous year. For more information about the review process, visit