A non-government entity
Anthem Medicare Advantage (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Anthem Medicare Advantage (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Anthem Medicare Advantage (HMO-POS) in 2026, please refer to our full plan details page.
Anthem Medicare Advantage (HMO-POS) is a HMO-POS plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Santa Clara County. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Anthem Medicare Advantage (HMO-POS) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Anthem Medicare Advantage (HMO-POS).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Anthem Medicare Advantage (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2899.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Anthem Medicare Advantage (HMO-POS) plan features an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, Tier 1 preferred generic drugs have no copay at preferred pharmacies, standard pharmacies, and standard mail. For Tier 2 standard generic drugs, you will pay a $42 copay at preferred pharmacies and standard mail, or a $47 copay at standard pharmacies. For Tier 3 preferred brand drugs, you will pay a 25% coinsurance, while Tier 4 non-preferred drugs carry a 33% coinsurance. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D prescriptions.
Additional Benefits
The Anthem Medicare Advantage (HMO-POS) plan offers comprehensive medical coverage with predictable cost-sharing, featuring no copays or coinsurance for primary care and specialist doctor visits. For emergency situations, the plan charges a $150 copay for emergency room visits, which is waived if you are admitted, and a $10 copay for urgent care. Inpatient hospital stays require a daily copay of $95 for the first five days and no copay for subsequent days, while most diagnostic, lab, and home health services are available with no copay or coinsurance. This plan also includes valuable supplemental benefits, providing routine dental, vision, and hearing exams with no copays or coinsurance. Members receive allowances of up to $175 annually for eyewear and up to $3,000 for prescription hearing aids with no copay or coinsurance. Additionally, durable medical equipment features 0% to 20% coinsurance with no copay, and skilled nursing facility stays are covered with no copay for the first 20 days.
Inpatient Hospital See details
Anthem Medicare Advantage (HMO-POS) partially covers inpatient hospital services with no coinsurance, excluding non-Medicare-covered stays and acute upgrades. Acute stays require a $95 daily copay for days 1 to 5 and no copay for days 6 to 90 (plus unlimited additional days), while psychiatric stays require a $120 daily copay for days 1 to 5 and no copay thereafter.
Outpatient Services See details
Outpatient services are covered by Anthem Medicare Advantage (HMO-POS) with no coinsurance, featuring a $0 to $200 copay for outpatient hospital services and a $200 copay for observation services. Ambulatory surgical center and outpatient blood services require no copay, while outpatient substance abuse sessions have a $25 copay.
Partial Hospitalization See details
Anthem Medicare Advantage (HMO-POS) covers partial hospitalization services with a $40.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Anthem Medicare Advantage (HMO-POS) covers ground and air ambulance services with a $225 copay and no coinsurance, though prior authorization is required. Transportation services are partially covered, offering up to 8 one-way trips per year to plan-approved locations with no copay or coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Anthem Medicare Advantage (HMO-POS) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $10 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum limit with a $150 copay and no coinsurance.
Primary Care See details
Anthem Medicare Advantage (HMO-POS) provides partially covered Primary Care benefits, as podiatry services and routine chiropractic care are not covered. Covered services like primary care, specialist, and therapy visits have no copay and no coinsurance, while chiropractic, mental health, psychiatric, and opioid treatment services require a $20 to $25 copay and no coinsurance.
Preventive Services See details
Anthem Medicare Advantage (HMO-POS) partially covers preventive services with no copay and no coinsurance for covered benefits like annual exams, kidney disease education, and glaucoma screenings. Several services are not covered, including health education, in-home safety assessments, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, caregiver support, in-home support, smoking cessation, fitness benefits, disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Anthem Medicare Advantage (HMO-POS) with no copays, coinsurance, or deductibles, excluding inner ear, outer ear, and over the ear prescription hearing aids. Covered benefits include routine hearing exams, OTC hearing aids up to $300 annually, and other prescription hearing aids up to $3,000 annually.
Vision Services See details
Anthem Medicare Advantage (HMO-POS) partially covers vision services, offering one routine eye exam annually and eyewear with no copay and no coinsurance. Covered eyewear includes contact lenses, eyeglasses, lenses, and frames up to a $175 yearly limit, but upgrades are not covered.
Dental Services See details
Dental services are partially covered by Anthem Medicare Advantage (HMO-POS), offering Medicare dental services, annual oral exams, and cleanings with no copay and no coinsurance. While dental x-rays and fluoride treatments are available as optional supplemental benefits, orthodontic, restorative, endodontic, periodontic, prosthodontic, implant, and oral surgery services are not covered.
Home Infusion bundled Services See details
Anthem Medicare Advantage (HMO-POS) covers Home Infusion bundled Services, which require prior authorization and step therapy. Covered Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by Anthem Medicare Advantage (HMO-POS) with a 20% coinsurance and no copay.
Medical Equipment See details
Anthem Medicare Advantage (HMO-POS) covers medical equipment with no copays, featuring a 0% to 20% coinsurance for durable medical equipment (DME) and a 20% coinsurance for prosthetic devices and medical supplies. Diabetic supplies and therapeutic shoes are covered with no copay or coinsurance, and prior authorization is required for DME and prosthetics.
Diagnostic and Radiological Services See details
Anthem Medicare Advantage (HMO-POS) covers diagnostic and radiological services, requiring prior authorization and a doctor referral. Diagnostic procedures, lab services, and diagnostic radiology are covered with no copay and no coinsurance, while therapeutic radiology requires a 20% coinsurance and outpatient X-rays have no copay.
Home Health Services See details
Anthem Medicare Advantage (HMO-POS) covers Home Health Services with no copay and no coinsurance. Prior authorization and a doctor referral are required to access this benefit.
Cardiac Rehabilitation Services See details
Anthem Medicare Advantage (HMO-POS) indicates some services are covered under Cardiac Rehabilitation Services, but in practice, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered. Any covered services require prior authorization and have no copay and no coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Anthem Medicare Advantage (HMO-POS), as additional days beyond the Medicare-covered limit are not covered. Stays require prior authorization and have no coinsurance, with no copay for days 1 through 20 and a $218 daily copay for days 21 through 100.
Other Services See details
Anthem Medicare Advantage (HMO-POS) partially covers other services, providing acupuncture, over-the-counter items, and community resource support with no copay and no coinsurance. Meal benefits and dual eligible SNP services are not covered.
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