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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 Sacramento, San Francisco, and Yolo 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.
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 $2500.00 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. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you'll pay a $3 copay for preferred generic drugs at a preferred pharmacy or a $0 copay for preferred generic drugs through the mail. 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 provides coverage for a wide range of services, including inpatient and outpatient care, with varying copays depending on the service. Many services have no copay, such as primary care visits, routine hearing and eye exams, and home health services. The plan also covers emergency services, hearing aids, dental, and vision services, with copays and annual maximums in place for some services. Additional benefits include coverage for ambulance services, with a copay for ground and coinsurance for air, and transportation to health-related locations with no copay. Preventive services like annual physical exams are covered with no copay, and the plan also offers coverage for over-the-counter items, dialysis, and medical equipment, among other services. However, certain services like cardiac rehabilitation and additional hours of home care are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For days 1-4, there is a $250 copay, and days 5-90 have no copay. Additional days for both Inpatient Hospital-Acute and Psychiatric are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $250, Observation Services with a $250 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $40 copay for both individual and group sessions, and Outpatient Blood Services with no copay. Prior authorization and a doctor referral are required for some services.
Partial Hospitalization See details
Partial hospitalization is covered under the Anthem Prime (HMO-POS) plan, requiring prior authorization, with a $40 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Anthem Prime (HMO-POS), including ground and air ambulance services. Ground ambulance services have a $250 copay, while air ambulance services have a 20% coinsurance; transportation services to a plan-approved health-related location have no copay, and up to 60 one-way trips are covered each year.
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 $35 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $90 copay, with a maximum plan benefit of $100,000.
Primary Care See details
The Anthem Prime (HMO-POS) plan covers primary care physician services with no copay. Chiropractic services have a $20 copay, but routine care is not covered. Occupational therapy services have a $25 copay. Physician specialist services have a $25 copay, and mental health specialty services have a $40 copay for individual and group sessions. Podiatry services have a copay between $0 and $25, and routine foot care is covered. Other health care professional services have a copay between $0 and $20. Psychiatric services have a $40 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have no copay. Opioid treatment program services have a $40 copay.
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 fitness benefits, remote access technologies, and home and bathroom safety devices, have a copay and may have a maximum plan benefit coverage amount. Several services, including health education, are not covered.
Hearing Services See details
Hearing services include coverage for hearing exams with a $25 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids have a maximum benefit of $1500 per year, and OTC hearing aids are covered with no copay up to a $300 maximum per year.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay between $0 and $25, while routine eye exams have no copay. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, and eyeglass frames, are covered with no copay and a combined maximum benefit of $200 per year.
Dental Services See details
The Anthem Prime (HMO-POS) plan covers dental services, with a $25 copay for Medicare dental services. Oral exams and prophylaxis (cleaning) have no copay, while other services like dental x-rays, fluoride treatments, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, removable, maxillofacial prosthetics, implant services, prosthodontics, fixed, oral and maxillofacial surgery, and orthodontics are covered. This plan has a maximum benefit of $500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Anthem Prime (HMO-POS) plan, with a $35 copay for Medicare Part B Insulin Drugs. The plan also covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Anthem Prime (HMO-POS) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Under the Anthem Prime (HMO-POS) plan, diagnostic and radiological services are covered. Diagnostic Procedures/Tests have a copay between $0 and $50, while Lab Services have no copay. Diagnostic Radiological Services have a copay between $10 and $175, and Outpatient X-Ray Services have a $10 copay. Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under 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. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Anthem Prime (HMO-POS) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $188. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items with no copay, up to a maximum of $100 every three months, and Medicare Community Resource Support with no copay. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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