2022 Anthem l MaineHealth Advantage Access (PPO)

Anthem l MaineHealth Advantage Access (PPO) H9219-001 is a 2022 Medicare Advantage Plan or Part-C by AMH Health available to residents in Maine. This plan includes additional prescription drug (Part-D) coverage. The Anthem l MaineHealth Advantage Access (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,800 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,800 out-of-pocket. This can be a extremely nice safety net.

Anthem l MaineHealth Advantage Access (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

AMH Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Anthem l MaineHealth Advantage Access (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from AMH Health and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from AMH Health except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 AMH Health Medicare Advantage Plan Costs

Anthem l MaineHealth Advantage Access (PPO) Part-C Premium

AMH Health charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H9219-001 Part-D Deductible and Premium

Anthem l MaineHealth Advantage Access (PPO) has a monthly drug premium of $0.00 and a $400.00 drug deductible. This AMH Health plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by AMH Health above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

AMH Health Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This AMH Health plan does offer additional coverage through the gap.

H9219-001 Formulary or Drug Coverage

Anthem l MaineHealth Advantage Access (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Anthem l MaineHealth Advantage Access (PPO) H9219-001 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$3	$8
Tier 2	$10	$15
Tier 3	$42	$47
Tier 4	$95	$100
Tier 5	26%	26%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 Anthem l MaineHealth Advantage Access (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$1,000 annual deductible

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$100-200 copay
Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0-80 copay
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Lab services	40% coinsurance (Out-of-Network)
Lab services	$0-10 copay
Outpatient x-rays	$20-40 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0 copay
Primary	40% coinsurance per visit (Out-of-Network)
Specialist	$35 copay per visit
Specialist	40% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

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

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Foot Care (podiatry services)

Foot exams and treatment	$35 copay
Foot exams and treatment	40% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$295 copay (Out-of-Network)
$295 copay

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Hearing

Fitting/evaluation	20% coinsurance (Out-of-Network)
Fitting/evaluation	$0 copay
Hearing aids	$0 copay
Hearing aids	$0 copay (Out-of-Network)
Hearing exam	40% coinsurance (Out-of-Network)
Hearing exam	$35 copay

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Inpatient Hospital Coverage

$300 per day for days 1 through 6 $0 per day for days 7 through 90
40% per stay (Out-of-Network)

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Medical Equipment/Supplies

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

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Medicare Part B Drugs

Chemotherapy	40% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	40% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$290 per day for days 1 through 6 $0 per day for days 7 through 90
Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)

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MOOP

$10,000 In and Out-of-network $5,800 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$0-250 copay per visit
40% coinsurance per visit (Out-of-Network)

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Package #1

Deductible
Monthly Premium	$24.00

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Package #2

Deductible
Monthly Premium	$34.00

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Package #3

Deductible
Monthly Premium	$55.00

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Preventive Care

$0 copay
40% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	$0 copay
Cleaning	20% coinsurance (Out-of-Network)
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	$0 copay
Oral exam	20% coinsurance (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	40% coinsurance (Out-of-Network)
Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay
Physical therapy and speech and language therapy visit	40% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100
40% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Anthem l MaineHealth Advantage Access (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.