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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 Select Counties in CA. 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 $1200.00 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'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have a $7 copay at a preferred pharmacy and a $0 copay for standard mail order, while standard generic drugs have 20% coinsurance at a preferred pharmacy and 20% coinsurance for standard mail order. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $250 copay for the first five days, and then no copay. Emergency services have a $90 copay, while primary care visits, eye exams, and dental cleanings have no copay. The plan also includes coverage for outpatient services, vision, and dental care, as well as medical equipment and home health services. Hearing exams, chiropractic services, and specialist visits have copays.
Inpatient Hospital See details
Inpatient Hospital coverage, including services not usually covered by Medicare, requires prior authorization and has a copay of $250 for days 1-5, and no copay for days 6-90. Additional days for inpatient hospital acute and psychiatric are covered, and non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services have a copay between $0 and $250, and Observation Services have a $250 copay, while Ambulatory Surgical Center Services and Outpatient Blood Services have no copay. Individual and group sessions for outpatient substance abuse have a copay of $10.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Prime (HMO-POS) plan, with a $10 copay. Prior authorization is required.
Ambulance and Transportation Services See details
The Anthem Prime (HMO-POS) plan covers ambulance and transportation services. Ground ambulance services have a $250 copay, while air ambulance services have a 20% coinsurance; however, 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 and Worldwide Emergency Coverage have a $90 copay, Urgently Needed Services have a $35 copay, and Worldwide Urgent Coverage and Worldwide Emergency Transportation also have a $90 copay.
Primary Care See details
The Anthem Prime (HMO-POS) plan covers primary care physician services with no copay. Chiropractic services have a $20 copay and require prior authorization and a doctor referral, but routine chiropractic care is not covered. Occupational therapy services have a $10 copay, and physician specialist services have a $10 copay. Mental health specialty services and podiatry services have a copay that varies between $0 and $10. Other health care professional services and psychiatric services have a copay that varies between $0 and $20. Physical therapy and speech-language pathology services have a $10 copay, and additional telehealth benefits have no copay. Opioid treatment program services have a $10 copay.
Preventive Services See details
The Anthem Prime (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including fitness and remote access technologies, have a copay, and other services like health education and home safety assessments are not covered.
Hearing Services See details
Hearing Services include hearing exams and prescription hearing aids. Hearing exams have a $10 copay, and routine hearing exams are covered with no copay. Prescription hearing aids and fitting/evaluation for hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services includes coverage for eye exams with a copay between $0 and $10, and eyewear with no copay. Routine eye exams, contact lenses, eyeglasses (lenses and frames), and eyeglass lenses are covered with no copay. Eyewear has a combined maximum plan benefit coverage amount of $100 every year, while upgrades are not covered.
Dental Services See details
The Anthem Prime (HMO-POS) plan offers dental coverage, including oral exams and prophylaxis (cleaning) with no copay, but only one oral exam and one cleaning are covered per year. Dental X-Rays and Fluoride Treatment are offered as optional supplemental benefits, so you may have to pay more for access to these benefits. Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
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 is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has no copay, and a coinsurance between 0% and 20%, but Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have no copay, and a 20% coinsurance. 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 a copay between $0 and $50, lab services with no copay, diagnostic radiological services with a copay between $10 and $150, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $10 copay. All services require prior authorization and a doctor's referral.
Home Health Services See details
Home Health Services are covered by Anthem Prime (HMO-POS) with no copay and no coinsurance. 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 under the Anthem Prime (HMO-POS) plan, but require prior authorization. There is no copay for days 1-20, and a $188 copay for days 21-100; additional days beyond Medicare-covered are not covered.
Other Services See details
The Anthem Prime (HMO-POS) plan covers Over-the-Counter (OTC) Items with no copay. Acupuncture, Meal Benefits, 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. Other 1 is covered with no copay and a doctor's referral.
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