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September 11, 2025
Anthem MAPD PPO/HMO Replacement
Benefit Comparison
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MAPD Medical Benefit Comparison
In-Force Anthem MAPD PPO/HMO Alignment MAPD PPO
Medical Deductible $0 $0 $0
Medical Maximum Out-of-Pocket $3,400 $3,000 $3,400
Primary Care Visit $10 $5 $10
Specialist Visit $20 $15 $20
Inpatient Hospital Care $0 per admit $0 per admit $0 per admit Outpatient Surgery $20 $0 $0
Inpatient Mental Health & Substance
Abuse $0 per admission $0 per admission $20
Outpatient Mental Health & Substance
Abuse $20 per visit $15 per visit $20
Skilled Nursing Facility $0, Days 1-100 $0, Days 1 - 100 $0, Days 1-100 Urgent Care Center $20, waived if admitted within 72
hours
$15, waived if admitted within 72
hours $20
Emergency Room $75, waived if admitted within 72
hours
$50, waived if admitted within 72
hours $75
Ambulance $50 per one way trip $50 per one way trip $50 Durable Medical Equipment 5% coinsurance per purchase $0 $0 © Copyright 2025 RetireeFirst, LLC. 4
MAPD Ancillary Benefit Comparison
In-Force Anthem MAPD PPO/HMO Alignment MAPD PPO
Foreign Travel Coverage
$75, Emergency Room
$20, Urgently Needed Care-waived if
admitted within 24 hours
$50, Emergency Room
$15, Urgently Needed Care-waived if
admitted within 72 hours
$0/$25,000 coverage limit per year.
Hearing
$0, Routine Hearing Exam – 1 per year
$500 – per ear – with a $1,000 maximum
benefit every 3 years
$0, Routine Hearing Exam – 1 per year
$500 – per ear – with a $1,000 maximum
benefit every 3 years
In-Network Only: $195.00 - $1,750.00 copay
per hearing
aid. 2 hearing aids every year
Vision
$0, Routine Hearing Exam – 1 per year
$100 maximum benefit every two calendar
years combined in and out of network
$0, Routine Hearing Exam – 1 per year
$100 maximum benefit every two calendar
years
$0 copay for exam/yr.
$0 copay for glasses/contacts every year.
($100 coverage limit)
Dental $20 copay for Medicare covered nonroutine care
$15 copay for Medicare covered nonroutine care Medicare Covered Services Podiatry $10, 12 Visits per year $5, 12 visits per year $0, 12 Visits per year Chiropractic $20 copay for Medicare covered services $15 copay for Medicare covered services $0, 24 Visits per year combined with Acupuncture
Acupuncture $10 copay for Medicare covered services $5 copay for Medicare covered services $0, 24 Visits per year combined with Chiropractic
Fitness Included Included Included
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MAPD RX Benefit Comparison
In-Force Anthem MAPD PPO/HMO Alignment MAPD PPO
Prescription Deductible $0 $0 $0
Retail 30 Day Supply
Tier 1 Generics $0 Select/$5 $0 Select/$5 $0 Preferred/$5 Tier 2 (Brands) $20 $20 $20
Tier 3 (NP Brands) $50 $50 $50
Tier 4 (Specialty) $50 $50 $50
Retail 90 Day Supply
Tier 1 Generics $0 Select/$15 $0 Select/$15 $0 Preferred/$15 Tier 2 (Brands) $60 $60 $60
Tier 3 (NP Brands) $150 $150 $150
Tier 4 (Specialty) Limited to a one month supply Limited to a one month supply Mail-Order 90 Day Supply
Tier 1 Generics $0 Select/$10 $0 Select/$10 $0 Preferred/$10 Tier 2 (Brands) $40 $40 $40
Tier 3 (NP Brands) $100 $100 $100
Tier 4 (Specialty) Limited to a one month supply Limited to a one month supply Part D Coverage Specifications
Prescription Maximum Out-of-Pocket $2,100 CMS Requirement $2,100 CMS Requirement RX Tiers 4 Tier 5 Tier
Drug Formulary Most Comprehensive (Open) Most Comprehensive (Open) Lifestyle Drugs Covered Yes Yes
Non-Part D Drugs Covered Yes Yes
Utilization Management Prior Authorizations, Quantity Limits and Step Therapy Prior Authorizations, Quantity Limits and Step Therapy Coverage Gap Does Not Apply in 2026 Does Not Apply in 2026 Catastrophic Coverage Members Pay $0 Members Pay $0
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MAPD Rate Comparison by Carrier
MAPD PPO/HMO Enrollment - 46
Lives
2026 Anthem Renewal
MAPD PPO/HMO Alignment MAPD PPO
PMPM
PPO
$561.18
HMO
$465.05
PPO
$385.00
Medical
$233.54
RX
$327.64
Medical
$143.61
RX
$321.44
Medical
$247.14
RX
$137.86
Total Cost $284,074.60 $212,520.00
PMPM
Differential
PPO
$176.18
HMO
$80.05
% Savings 35.08%
Annual Savings $71,554.60