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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 Fresno, King, Madera and Tulare 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 $2900.00 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 offers an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you will have no copay for Tier 1 preferred generic drugs at preferred pharmacies, standard pharmacies, and standard mail delivery. For other tiers, you will pay a $42 to $47 copay for Tier 2 standard generics, 25% coinsurance for Tier 3 preferred brands, and 33% coinsurance for Tier 4 non-preferred drugs. These cost-sharing rates apply until your yearly out-of-pocket drug costs reach $2,100. Once you reach this limit, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, beneficiaries who qualify for the full Low-Income Subsidy will benefit from a reduced cost of $0.00.
Additional Benefits
Anthem Prime (HMO-POS) offers affordable everyday healthcare coverage, featuring no copay for primary care, specialist, telehealth, and preventive visits. If you require hospital care, inpatient stays carry a $225 daily copay for the first five days and no copay for days six through ninety, while emergency room visits have a $150 copay. Outpatient surgical services and diagnostic lab tests are also highly accessible with no copay. In addition to medical care, the plan provides valuable routine benefits including no copay for annual dental, vision, and hearing exams. Members also receive allowances for eyewear and hearing aids, alongside no copay for over-the-counter items and diabetic supplies. While specialized services like dialysis and durable medical equipment require up to 20% coinsurance, home health care is fully covered with no copay or coinsurance.
Inpatient Hospital See details
Anthem Prime (HMO-POS) partially covers inpatient hospital benefits, requiring a $225 daily copay for days 1 through 5 and no copay for days 6 through 90, with no coinsurance for acute and psychiatric stays. Prior authorization is required, and while unlimited additional days are covered at no copay, upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Anthem Prime (HMO-POS) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services, a $40 copay for outpatient substance abuse sessions, and copays ranging from $0 to $225 for outpatient hospital and observation stays. Most of these covered outpatient services require prior authorization and a doctor referral.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Anthem Prime (HMO-POS) with a $40.00 copay and no coinsurance. Prior authorization is required to access these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered under Anthem Prime (HMO-POS), with ground and air ambulance services requiring a $250 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved and 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, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $35 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum limit with a $150 copay and no coinsurance.
Primary Care See details
Primary Care benefits are partially covered under Anthem Prime (HMO-POS) with no coinsurance, as routine chiropractic care is not covered. There is no copay for primary care, specialist, telehealth, and podiatry visits, while other services like therapy, psychiatric care, and opioid treatment require copays ranging from $15 to $40.
Preventive Services See details
Anthem Prime (HMO-POS) partially covers preventive services, offering covered benefits like annual physical exams, remote access technologies, and kidney disease education with no copay and no coinsurance. However, several sub-services are not covered, including fitness benefits, weight management programs, health education, and home safety assessments.
Hearing Services See details
Anthem Prime (HMO-POS) covers hearing services with no copay and no coinsurance, including annual routine hearing exams and fitting evaluations. Hearing aids are also covered with no copay or coinsurance up to $300 yearly for OTC devices and $2,000 yearly for prescription aids, though prescription hearing aids are partially covered as inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Vision Services under Anthem Prime (HMO-POS) are partially covered, offering no copay and no coinsurance for annual routine eye exams and eyewear, which includes a $150 yearly limit. Covered eyewear includes contact lenses and eyeglasses, but upgrades are not covered.
Dental Services See details
Anthem Prime (HMO-POS) covers Medicare dental services, annual oral exams, and cleanings with no copay and no coinsurance, though dental X-rays and fluoride are optional supplemental benefits. The dental benefit is partially covered because restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, adjunctive general services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under Anthem Prime (HMO-POS) with prior authorization and step therapy required. Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require no copay and 0% to 20% coinsurance.
Dialysis Services See details
Anthem Prime (HMO-POS) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Anthem Prime (HMO-POS), offering no copay for diabetic supplies and therapeutic shoes. Durable medical equipment requires prior authorization with coinsurance ranging from no coinsurance to 20%, while prosthetic devices and medical supplies require prior authorization and carry a 20% coinsurance.
Diagnostic and Radiological Services See details
Anthem Prime (HMO-POS) covers diagnostic and radiological services, with prior authorization and doctor referrals required for all services. Lab services and outpatient X-rays have no copay or coinsurance, while diagnostic tests range from no copay up to $200, diagnostic radiology ranges from no copay up to $210, and therapeutic radiology requires a 20% coinsurance with no copay.
Home Health Services See details
Anthem Prime (HMO-POS) covers home health services with no copay and no coinsurance, although a doctor referral and prior authorization are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered under Anthem Prime (HMO-POS), meaning some services are covered, but in practice, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered. There are no copay or coinsurance benefits available for these services since they are not covered under the plan.
Skilled Nursing Facility (SNF) See details
Anthem Prime (HMO-POS) partially covers Skilled Nursing Facility (SNF) services, which require prior authorization but do not require a prior three-day inpatient hospital stay. Covered stays feature no copay or coinsurance for days 1 through 20, and a $218 daily copay with no coinsurance for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Anthem Prime (HMO-POS), featuring Medicare Community Resource Support and over-the-counter items with no copay and no coinsurance. Acupuncture, meal benefits, and Dual Eligible SNPs are not covered under this plan.
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