In-network
Inpatient hospital
Tier 1: 35% coinsurance
Not separately reported
2027 Medicare plan code
Medicare Plan
Anthem Veteran (PPO) · Anthem Blue Cross and Blue Shield · Local PPO · Select counties in Virginia
Full CMS plan ID: H4909-020-000
H4909-020-000 is the full CMS identifier for the H4909-020 Medicare plan. Common searches include H4909 020 and H4909020.
In-network
Tier 1: 35% coinsurance
Not separately reported
Emergency transport
Emergency services
$115 copay
Medical maximum
Skilled care at home
Monthly cost
CMS reports a Part B premium reduction of $80 per month.
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In: Primary Care Physician Services: $0 copay · Out: 7a: $35 copay
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In: Physician Specialist Services: $45 copay · Out: 7d: $60 copay
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In: Annual Physical Exam: $0 copay; Kidney Disease Education Services: $0 copay; Glaucoma Screening: $0 copay; Diabetes Self-Management Training: $0 copay; Digital Rectal Exams: $0 copay; EKG following Welcome Visit: $0 copay · Out: 14b: 35% coinsurance; 14d: 35% coinsurance; 14e1: 35% coinsurance; 14e2: 35% coinsurance; 14e4: 35% coinsurance; 14e5: 35% coinsurance; 14a: 35% coinsurance
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In: Diagnostic Procedures/Tests: $0–$140 copay · Out: 8a1: 35% coinsurance
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In: Lab Services: $0–$15 copay · Out: 8a2: 35% coinsurance
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In: Outpatient X-Ray Services: $50–$110 copay · Out: 8b3: 35% coinsurance
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In: Diagnostic Radiological Services: $50–$290 copay · Out: 8b1: 35% coinsurance
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In: Urgently Needed Services: $40 copay · Out: Not separately reported
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In: $115 copay · Out: Not separately reported
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In: $285 copay · Out: $285 copay
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In: $285 copay · Out: $285 copay
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In: Outpatient Hospital Services: $0–$290 copay; Observation Services: $290 copay · Out: 9a1: 35% coinsurance; 9a2: 35% coinsurance
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In: Ambulatory Surgical Center (ASC) Services: $0–$240 copay · Out: 9b: 35% coinsurance
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In: $0 copay · Out: 35% coinsurance
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In: Skilled nursing facility: Tier 1: $0 / day for days 1–20; $218 / day for days 21–100 · Out: Skilled nursing facility: Tier 1: 35% coinsurance
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In: Cardiac Rehabilitation Services: $30 copay; Intensive Cardiac Rehabilitation Services: $30 copay; Pulmonary Rehabilitation Services: $15 copay; SET for PAD Services: $20 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: 3-1: 35% coinsurance; 3-2: 35% coinsurance; 3-3: 35% coinsurance; 3-4: 35% coinsurance
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In: Occupational Therapy Services: $35 copay · Out: 7c: 35% coinsurance
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In: Physical Therapy and Speech-Language Pathology Services: $35 copay · Out: 7i: 35% coinsurance
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In: Partial Hospitalization Program: $40 copay; Individual Sessions for Mental Health Specialty Services: $45 copay; Group Sessions for Mental Health Specialty Services: $45 copay; Individual Sessions for Psychiatric Services: $45 copay; Group Sessions for Psychiatric Services: $45 copay; Inpatient psychiatric hospital: Tier 1: $290 / day for days 1–5; $0 / day for days 6–90 · Out: 5a: 35% coinsurance; 7e1: 35% coinsurance; 7e2: 35% coinsurance; 7h1: 35% coinsurance; 7h2: 35% coinsurance; Inpatient psychiatric hospital: Tier 1: 35% coinsurance
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In: Intensive Outpatient Program Services: $40 copay; Individual Sessions for Outpatient Substance Abuse: $45 copay; Group Sessions for Outpatient Substance Abuse: $45 copay · Out: 5b: 35% coinsurance; 9c1: 35% coinsurance; 9c2: 35% coinsurance
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In: Podiatry Services: $45 copay; 7f(NMC): Not applicable · Out: 7f: $60 copay
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In: Chiropractic Services: $15 copay · Out: 7b: 35% coinsurance
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In: Medicare Dental Services: $0 copay; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 copay; Dental X-Rays: $0 copay; Other Diagnostic Dental Services: $0 copay; Prophylaxis (Cleaning): $0 copay; Fluoride Treatment: $0 copay; Other Preventive Dental Services: $0 copay; Restorative Services: 25% coinsurance; Endodontics: 25% coinsurance; Periodontics: 25% coinsurance; Prosthodontics, removable: 25% coinsurance; Prosthodontics, fixed: 25% coinsurance; Oral and Maxillofacial Surgery: 25% coinsurance; Adjunctive General Services: 25% coinsurance · Out: 16a: $0 copay; 16b1: 20% coinsurance; 16b2: 20% coinsurance; 16b3: 20% coinsurance; 16b4: 20% coinsurance; 16b5: 20% coinsurance; 16b6: 20% coinsurance; 16c1: 50% coinsurance; 16c2: 50% coinsurance; 16c3: 50% coinsurance; 16c4: 50% coinsurance; 16c7: 50% coinsurance; 16c8: 50% coinsurance; 16c10: 50% coinsurance
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In: Eye Exams: $0–$45 copay; Routine Eye Exams: $0 copay; Other Eye Exam Services: Not applicable; Eyewear: $0 copay; Contact Lenses: $0 copay; Eyeglasses (lenses and frames): $0 copay; Eyeglass lenses: $0 copay; Eyeglass frames: $0 copay; Upgrades: Not applicable · Out: 17a: $60 copay; 17a1: $0 copay; 17b: $60 copay; 17b1: $0 copay; 17b2: $0 copay; 17b3: $0 copay; 17b4: $0 copay
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In: Hearing Exams: $45 copay; Routine Hearing Exams: $0 copay; Fitting/Evaluation for Hearing Aid: $0 copay; Prescription Hearing Aids (all types): $0 copay; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable; OTC Hearing Aids: $0 copay · Out: 18a: $60 copay; 18a1: 20% coinsurance; 18a2: 20% coinsurance; 18b1: 80% coinsurance; 18c: 80% coinsurance
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In: 10b(NMC): Not applicable · Out: Not separately reported
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In: Fitness Benefit: $0 copay · Out: 14c4: 75% coinsurance
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In: Over-the-Counter (OTC) Items: $0 copay · Out: 13b: $0 copay
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In: Meal Benefit: Not applicable · Out: Not separately reported
Plan details
No benefits match that search.
$0 Part C premium / month · CMS reports a Part B premium reduction of $80 per month.
$750
Not separately reported
Not reported
Local PPO · Referrals: Not required · Out-of-network coverage: Yes
Not reported
Using this plan
Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
Anthem Veteran (PPO) is a 2027 Local PPO offered by Anthem Blue Cross and Blue Shield in Select counties in Virginia. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $1,450 across 5 charged days.
Common benefit costs
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Separate visits or services; costs are not added together.
The service setting and billing details can change what you pay.
5 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.
Helpful context
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports a Part B premium reduction of $80 per month.
Availability
Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
Plan-specific answers
Anthem Veteran (PPO) is listed for Select counties in Virginia (VA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $6,800. Prescription drug spending generally does not count toward this medical limit.
The listed Part C premium is $0 per month. This does not replace the standard Medicare Part B premium.
The plan record lists $115 copay.
Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.
Plan context
H4909-020-000H4909H4909-020000County/service-area foundation
Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.
91 additional service-area entries are retained in the data record.
Exact county navigation
These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.
About this code
H4909-020-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H4909-020, H4909 020, or the compact full CMS ID H4909020000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.