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 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 Select Counties in CA. 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 a $110.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
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) Medicare plan features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $110.00. During the initial coverage phase, Tier 1 preferred generic drugs are available with no copay at preferred pharmacies and through standard mail, while standard pharmacies require a $10.00 copay. For other formulary tiers, you will pay a coinsurance of 25% for standard generics, 30% for preferred brands, and 31% for non-preferred drugs. These cost-sharing rates remain in effect until your total yearly drug costs reach $2,100.00. Once you reach this $2,100.00 limit and enter the catastrophic coverage phase, you will pay nothing for covered Medicare Part D prescriptions. Beneficiaries who qualify for the Extra Help low-income subsidy will also benefit from a reduced $0.00 premium.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers comprehensive coverage for core medical needs, featuring no copay and no coinsurance for primary care, telehealth, and preventive visits. For inpatient hospital stays, members pay a daily copay of $250 for days one through five, followed by no copay for days six through ninety. Emergency room visits require a $150 copay, which is waived if admitted within 24 hours, while urgent care services are available for a $35 copay. Routine vision and dental services are well-supported, offering annual cleanings, routine eye exams, and standard eyewear with no copay and no coinsurance. Specialist visits, diagnostic lab tests, and home health services also feature low to no copays, though dialysis and durable medical equipment may require up to a 20% coinsurance. Additionally, the plan provides a quarterly allowance of up to $38 for over-the-counter health items with no copay.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Anthem Prime (HMO-POS), as upgrades and non-Medicare-covered stays are not covered. For covered acute and psychiatric stays, there is a $250 daily copay for days 1 to 5, no copay for days 6 through 90 (including unlimited additional days), and no coinsurance.
Outpatient Services See details
Anthem Prime (HMO-POS) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Other covered benefits require a copay, including $10 for outpatient substance abuse sessions and a copay ranging from no copay up to $250 for outpatient hospital and observation services.
Partial Hospitalization See details
Anthem Prime (HMO-POS) covers partial hospitalization benefits with a $10.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Anthem Prime (HMO-POS), which offers ground and air ambulance services for a $250 copay and no coinsurance. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Anthem Prime (HMO-POS) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $35 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 lifetime maximum with a $150 copay and no coinsurance.
Primary Care See details
Anthem Prime (HMO-POS) covers primary care and telehealth visits with no copay and no coinsurance. Other services like specialist, therapy, and mental health visits require copays between $10 and $20 with no coinsurance, though chiropractic services are only partially covered as routine care is excluded.
Preventive Services See details
Anthem Prime (HMO-POS) covers preventive services, including annual physical exams, remote access technologies, and kidney disease education, with no copay and no coinsurance. However, the plan only partially covers additional preventive services, excluding benefits such as fitness programs, health education, weight management, and personal emergency response systems. Referrals are required for kidney disease education and other specific preventive screenings.
Hearing Services See details
Anthem Prime (HMO-POS) partially covers hearing exams with no deductible, no coinsurance, and a $10 copay, though one routine hearing exam per year is available with no copay and fitting or evaluation exams are not covered. For prescription hearing aids, some services are covered, but all sub-services—including inner ear, outer ear, over-the-ear, and general prescription hearing aids—are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services are partially covered by Anthem Prime (HMO-POS), as eyewear upgrades are not covered. Routine eye exams and covered eyewear have no copay or coinsurance, though other eye exams may require up to a $10 copay, with a combined $150 annual limit on eyewear.
Dental Services See details
Dental services are partially covered by Anthem Prime (HMO-POS), offering Medicare dental services for a $10 copay and no coinsurance, as well as annual oral exams and cleanings with no copay and no coinsurance. Dental X-rays and fluoride treatments are available as optional supplemental benefits, while restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Anthem Prime (HMO-POS) covers home infusion bundled services with prior authorization, offering Medicare Part B insulin drugs for a $35 copay and no coinsurance. Other covered Part B drugs, including chemotherapy and radiation drugs, have no copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Anthem Prime (HMO-POS) covers dialysis services to support your ongoing kidney care needs. Under this plan, you will pay a 20% coinsurance and no copay for covered dialysis treatments.
Medical Equipment See details
Anthem Prime (HMO-POS) covers medical equipment, featuring no coinsurance to 20% coinsurance for durable medical equipment and 20% coinsurance for prosthetics and medical supplies. Diabetic supplies, therapeutic shoes, and inserts are 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 a doctor referral. Lab services have no copay, while diagnostic tests range from a $0 to $50 copay, both with no coinsurance. Outpatient X-rays carry a $10 copay and diagnostic radiology ranges from a $10 to $150 copay, both with no coinsurance, while therapeutic radiology requires a 20% coinsurance with no copay.
Home Health Services See details
Home health services are covered under the Anthem Prime (HMO-POS) plan with no copay and no coinsurance. Members will need to obtain a doctor referral and prior authorization to access these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Anthem Prime (HMO-POS) plan. This includes cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services, all of which are not covered by the plan.
Skilled Nursing Facility (SNF) See details
Anthem Prime (HMO-POS) partially covers Skilled Nursing Facility (SNF) services, as additional days beyond the Medicare-covered limit are not covered. Patients pay no copay and no coinsurance for days 1 through 20, and a $218 daily copay with no coinsurance for days 21 through 100, with prior authorization required.
Other Services See details
Other Services are partially covered by Anthem Prime (HMO-POS), offering no copay and no coinsurance for Medicare Community Resource Support and over-the-counter items up to a $38 quarterly limit. Acupuncture, meal benefits, and Dual Eligible SNPs are not covered.
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