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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 2026, 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 2026.
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) Medicare plan features an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you pay no copay for Tier 1 preferred generic drugs at preferred pharmacies and standard mail, or a $5 copay at standard pharmacies. Other tiers require coinsurance, ranging from 15% for standard generics at preferred pharmacies up to 33% for non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, beneficiaries who qualify for the low-income subsidy can reduce their Part D costs to zero.
Additional Benefits
Anthem Prime (HMO-POS) offers comprehensive healthcare coverage with predictable out-of-pocket costs, featuring no copays or coinsurance for primary care visits, telehealth, home health services, and preventive care. For hospital stays, members pay a daily copay of $250 for the first four days and no copay for days five through ninety, with no coinsurance required. Outpatient services, emergency care, and specialist visits are also covered, typically requiring fixed copays ranging up to $250 with no coinsurance. The plan includes dental, vision, and hearing benefits, featuring no copays for routine exams, cleanings, and select eyewear or hearing aids up to specified annual limits. Members also benefit from no copays on diabetic supplies, lab services, and up to sixty one-way transportation trips to plan-approved locations. Prescription insulin is capped at a $35 copay, while durable medical equipment and dialysis services require no copay and up to twenty percent coinsurance.
Inpatient Hospital See details
Anthem Prime (HMO-POS) covers inpatient acute and psychiatric hospital stays with a $250 daily copay for days 1 through 4, no copay for days 5 through 90, and no coinsurance. Unlimited additional days are covered with no copay, although upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Anthem Prime (HMO-POS) with no coinsurance, though copays vary depending on the specific service. You will pay a $0 to $250 copay for outpatient hospital services, a $250 copay per stay for observation services, and a $40 copay for outpatient substance abuse sessions, while ambulatory surgical center and outpatient blood services require no copay.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Anthem Prime (HMO-POS) with a $40 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Anthem Prime (HMO-POS) covers ground and air ambulance services with a $219 copay and no coinsurance, requiring prior authorization. Transportation services are partially covered with no copay and no coinsurance for up to 60 one-way trips to plan-approved locations, while transportation to any health-related location is not covered.
Emergency Services See details
Anthem Prime (HMO-POS) covers emergency services with a $150 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $35 copay and no coinsurance, and worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum with a $150 copay and no coinsurance.
Primary Care See details
Primary Care benefits under Anthem Prime (HMO-POS) feature no copay and no coinsurance for primary care doctor visits and telehealth services, while specialist, therapy, and mental health visits require copays of up to $40 and no coinsurance. Chiropractic services are only partially covered, as routine chiropractic care is not covered.
Preventive Services See details
Preventive services are partially covered by Anthem Prime (HMO-POS) with no copay or coinsurance for covered options like annual physicals, fitness benefits, and glaucoma screenings. However, sub-services such as health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, tobacco cessation counseling, disease management, telemonitoring, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by Anthem Prime (HMO-POS), with no coverage for inner ear, outer ear, and over-the-ear prescription hearing aids. Covered diagnostic exams require a $25 copay, while routine exams, fitting evaluations, OTC hearing aids (up to $300 annually), and general prescription hearing aids (up to $1,500 annually) have no copay and no coinsurance.
Vision Services See details
Anthem Prime (HMO-POS) partially covers vision services, featuring routine eye exams with no copay and other eye exams with a $0 to $25 copay, with no coinsurance or deductibles. Eyewear is covered with no copay or coinsurance up to a $250 annual maximum, though upgrades are not covered.
Dental Services See details
Anthem Prime (HMO-POS) partially covers dental services, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental services require a $25 copay and no coinsurance, while covered preventive services like cleanings and oral exams have no copay and no coinsurance up to a $500 annual maximum.
Home Infusion bundled Services See details
Anthem Prime (HMO-POS) covers home infusion bundled services, requiring prior authorization and step therapy. Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs feature no copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Anthem Prime (HMO-POS) covers Dialysis Services with no copay and a 20% coinsurance. This benefit ensures you receive necessary treatment while maintaining clear expectations of your out-of-pocket expenses.
Medical Equipment See details
Anthem Prime (HMO-POS) covers medical equipment with 0% to 20% coinsurance and no copay for durable medical equipment, and 20% coinsurance and no copay for prosthetics and medical supplies. Diabetic supplies and therapeutic shoes or inserts are also covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Anthem Prime (HMO-POS) covers diagnostic and radiological services, requiring prior authorization and doctor referrals for these benefits. Under this plan, members pay no copay or coinsurance for lab services, a $0 to $50 copay with no coinsurance for diagnostic tests, a $10 copay with no coinsurance for X-rays, a $10 to $175 copay with no coinsurance for diagnostic radiology, and a 20% coinsurance with no copay for therapeutic radiology.
Home Health Services See details
Home health services are covered by Anthem Prime (HMO-POS) with no copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Cardiac Rehabilitation Services See details
Anthem Prime (HMO-POS) indicates that some services are covered, but Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered, meaning there is no copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Anthem Prime (HMO-POS) partially covers Skilled Nursing Facility (SNF) services, which require prior authorization and have no coinsurance. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Anthem Prime (HMO-POS) partially covers Other Services with no copay and no coinsurance for eligible benefits, which include Medicare Community Resource Support and a $67 quarterly Over-the-Counter (OTC) allowance. Acupuncture, meal benefits, and Dual Eligible SNPs are not covered under this plan.
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