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 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 Fresno, King, Madera and Tulare 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 $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:
Sign up for Anthem Prime (HMO-POS)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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. For example, you'll pay a $4 copay at a preferred pharmacy for preferred generic drugs, and 20% coinsurance for standard generic drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. This plan may also reduce your premium if you qualify for the low-income subsidy (LIS).
Additional Benefits
The Anthem Prime (HMO-POS) plan offers a wide range of benefits, including inpatient and outpatient services, with varying copays depending on the service. Emergency, preventive, and primary care services, such as annual physical exams and primary care visits, are covered with no copay. The plan also includes coverage for hearing, vision, and dental services, with no copay for routine hearing exams and eyewear, and oral exams and cleaning. Additional benefits include coverage for ambulance services, partial hospitalization, and home health services, with copays or coinsurance depending on the service. The plan also covers home infusion services, dialysis, and medical equipment. However, some services such as cardiac rehabilitation, additional hours of home health care, and certain other services are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, each with a copay of $225 for days 1-5, and no copay for days 6-90. Additional days for both Inpatient Hospital-Acute and Psychiatric are covered with no copay. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $225, Observation Services with a $225 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. All services require a doctor referral.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Prime (HMO-POS) plan, but requires prior authorization. You will pay a $40 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, offered by Anthem Prime (HMO-POS), cover both ground and air ambulance services, each with a $290 copay, and no coinsurance. 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 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.
Primary Care See details
The Anthem Prime (HMO-POS) plan covers primary care services with no copay, chiropractic services with a $15 copay, occupational therapy with a $20 copay, physician specialist services with no copay, and mental health specialty services with a $40 copay for individual and group sessions. The plan also covers podiatry services with no copay, other health care professional services with a copay between $0 and $20, psychiatric services with a $40 copay for individual and group sessions, physical therapy and speech-language pathology with a $20 copay, additional telehealth benefits with no copay, and opioid treatment program services with a $40 copay. Services may require prior authorization and a doctor referral.
Preventive Services See details
The Anthem Prime (HMO-POS) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, like Fitness Benefit and Remote Access Technologies, are covered with no copay. Other services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
The Anthem Prime (HMO-POS) plan covers hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and OTC hearing aids with no copay. The plan also covers prescription hearing aids (all types), with a maximum benefit of $1,500 per year, but does not cover prescription hearing aids for the inner, outer, or over the ear.
Vision Services See details
The Anthem Prime (HMO-POS) plan covers vision services, including eye exams and eyewear. There is no copay for eye exams and eyewear, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames, but upgrades are not covered, and there is a combined maximum of $100 per year for all eyewear.
Dental Services See details
Dental Services are covered, including oral exams and prophylaxis (cleaning) with no copay, and once per year. Dental X-Rays and Fluoride Treatment are also covered as optional supplemental benefits, so you may have to pay more for access. Orthodontic Services and other dental services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Anthem Prime (HMO-POS) plan. The plan has a $35 copay for Medicare Part B Insulin Drugs, and coinsurance between 0% and 20% for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis services are covered under the Anthem Prime (HMO-POS) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies - Non-Medicare benefit and Medical Supplies with a 20% coinsurance, and Diabetic Equipment with no copay for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Anthem Prime (HMO-POS), with a copay for Medicare-covered diagnostic procedures and tests, and lab services, ranging from $0 to $200, and a copay for diagnostic radiological services that can be up to $220. Therapeutic Radiological Services have a 20% coinsurance, and outpatient x-ray services have no copay.
Home Health Services See details
Home Health Services are covered by Anthem Prime (HMO-POS) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization and a referral are required for this benefit.
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 Anthem Prime (HMO-POS), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, there is a $140 copay.
Other Services See details
Under Other Services, acupuncture, meal benefits, 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. Over-the-counter items have no copay, and other 1 has no copay.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved