A non-government entity
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 San Diego County. 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 $17.00. 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 $2000.00 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:
Sign up for Anthem Prime (HMO-POS)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Anthem Prime (HMO-POS) plan has an "Enhanced Alternative" drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you will pay no copay for preferred generic drugs at preferred and standard pharmacies, and also no copay for preferred mail order. For standard generic drugs, you will pay 15% coinsurance at preferred pharmacies and mail order, and 20% coinsurance at standard pharmacies.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers a range of benefits, including inpatient hospital stays with a $150 copay for the first six days, and no copay for days 7-90. Many outpatient services, such as primary care, hearing exams, vision services, and dental services, are covered with no copay. Emergency services have a $90 copay, and ambulance services have a $250 copay for ground transport. This plan also includes coverage for home health services, diagnostic services, and skilled nursing facility stays. Other benefits include coverage for hearing aids up to $3,000 per year, and a maximum benefit of $300 per year for OTC hearing aids. The plan also covers OTC items with no copay, up to $85 every three months.
Inpatient Hospital See details
Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with a $150 copay for days 1-6 and no copay for days 7-90. Additional days are covered with no copay. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and outpatient substance abuse services are covered under the Anthem Prime (HMO-POS) plan. Outpatient hospital services have a copay between $0 and $225, observation services have a $225 copay, and outpatient substance abuse services have no copay for individual and group sessions. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services are also covered, with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by Anthem Prime (HMO-POS) with no copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Anthem Prime (HMO-POS), with a $250 copay for ground ambulance services and a 20% coinsurance for air ambulance services. Transportation services to a plan-approved health-related location are covered with no copay for up to 30 one-way trips per year, but 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 by Anthem Prime (HMO-POS). Emergency Services have a $90 copay, and Urgently Needed Services have a $35 copay, while Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $90 copay.
Primary Care See details
Anthem Prime (HMO-POS) covers primary care physician services, physician specialist services, physical therapy, speech-language pathology services, and additional telehealth benefits with no copay. Chiropractic services have a $5 copay, and mental health specialty services, podiatry services, other health care professional services, psychiatric services, and opioid treatment program services have varying copays.
Preventive Services See details
The Anthem Prime (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. Other preventive services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include hearing exams with no copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum benefit of $3,000 per year, and OTC hearing aids are covered with no copay and a maximum benefit of $300 per year.
Vision Services See details
The Anthem Prime (HMO-POS) plan covers vision services, including eye exams and eyewear, with no copay. Eyewear has a combined maximum benefit of $300 per year, and upgrades are not covered.
Dental Services See details
Dental Services are covered, including 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, all with no copay. This plan has a maximum benefit of $1500 every year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Anthem Prime (HMO-POS) plan and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Anthem Prime (HMO-POS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits under the Anthem Prime (HMO-POS) plan include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies with no copay and a 20% coinsurance for Medicare-covered items, and Diabetic Equipment. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with no copay, Lab Services with no copay, Diagnostic Radiological Services with a copay of at most $10, and Outpatient X-Ray Services with no copay. Therapeutic Radiological Services are covered with at most 20% coinsurance.
Home Health Services See details
Home health services are covered by the Anthem Prime (HMO-POS) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Anthem Prime (HMO-POS) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Anthem Prime (HMO-POS) with prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $100.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Other 1 services, with no copay, and a maximum plan benefit coverage amount of $85 every three months for OTC items. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved