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Anthem Prime (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Anthem Prime (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Anthem Prime (HMO-POS) in 2025, please refer to our full plan details page.
Anthem Prime (HMO-POS) is a HMO-POS plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Riverside and San Bernardino Counties. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Anthem Prime (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 Prime (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 Prime (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. Additionally, this plan comes with a Part B Premium reduction of $30.90. You must continue to pay paying your reduced 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 $800.00 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 Prime (HMO-POS) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay either a coinsurance or no copay depending on the drug tier and the pharmacy you use. For preferred generic drugs, there is no copay, while standard generic drugs have a 15-20% coinsurance. Preferred and non-preferred brand drugs have a 33-35% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers comprehensive coverage with a focus on minimizing out-of-pocket costs. Many services, including inpatient hospital stays, outpatient services, primary care visits, preventive services, hearing exams, vision exams, dental services, home health, and diagnostic services, are covered with no copay. The plan also provides coverage for ambulance and transportation, emergency services, and home infusion services, with varying copays or coinsurance amounts. This plan includes additional benefits like coverage for hearing aids, dental, and over-the-counter items, with specific limits. However, it's important to note that some services, such as cardiac rehabilitation, are not covered. Additionally, there are some services that require prior authorization, such as partial hospitalization and home infusion services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with no copay for Medicare-covered stays, and additional days are also covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, and Outpatient Blood Services have no copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay of $25.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Prime (HMO-POS) plan, with no copay required. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Anthem Prime (HMO-POS) plan. Ground and air ambulance services have a $150 copay, and transportation services to a plan-approved health-related location have no copay for up to 20 one-way trips per year, with rideshare services, bus/subway, van, and medical transport covered. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Anthem Prime (HMO-POS) plan. Emergency Services have a $90 copay, Urgently Needed Services have a $25 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $90 copay.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Primary Care Physician Services, Chiropractic Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Additional Telehealth Benefits have no copay. Individual and group sessions for Mental Health and Psychiatric services have a $25 copay. Occupational Therapy Services, Podiatry Services, Other Health Care Professional, and Opioid Treatment Program Services have a copay, but the amount is not specified.
Preventive Services See details
The Anthem Prime (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, kidney disease education services, and other preventive services are also covered, with some services requiring a referral and some having a copay. Fitness benefits and remote access technologies have a $0 copay. Other services like health education and home safety assessments are not covered.
Hearing Services See details
The Anthem Prime (HMO-POS) plan covers hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and OTC hearing aids with no copay. Prescription hearing aids are covered with a plan-specified amount of $3,000 per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Anthem Prime (HMO-POS) plan covers vision services, including eye exams and eyewear. Eye exams and all eyewear options except upgrades have no copay. The plan provides a combined maximum of $200 per year for all eyewear.
Dental Services See details
Dental Services are covered, with a maximum plan benefit of $1200 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are covered with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the Anthem Prime (HMO-POS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, but DME for use outside the home is not covered. Prosthetic Devices and Medical Supplies are covered with a 20% coinsurance, and Diabetic Equipment is covered with no copay for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Anthem Prime (HMO-POS) plan. Diagnostic Procedures/Tests have no copay, and Lab Services have no copay. Diagnostic Radiological Services and Therapeutic Radiological Services have a copay of up to $50, while Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Anthem Prime (HMO-POS) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Anthem Prime (HMO-POS) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Anthem Prime (HMO-POS) plan. There is no copay for days 1-20, and a $50 copay for days 21-100.
Other Services See details
Under "Other Services," Anthem Prime (HMO-POS) covers acupuncture with no copay and a limit of 24 treatments per year, and also covers over-the-counter items with no copay and a maximum benefit coverage amount of $85 every three months. This plan does not cover a meal benefit, and other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and Private Duty Nursing Services are not covered.
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