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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 Ventura County. 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 $3000.00 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 either a coinsurance or no copay depending on the drug tier and pharmacy type. For preferred generic drugs, there is no copay. For standard generic drugs, you'll pay 20-25% coinsurance, and for preferred brand drugs, you'll pay 35% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers a range of benefits with varying costs. You'll find no copays for primary care, preventive services, and many outpatient services. Hospital stays have a $300 copay for the first four days, and then no copay for the rest of the stay. The plan also includes coverage for emergency services, hearing, vision, and dental services. Some services have copays, such as specialist visits, and ambulance services. Other services are covered with coinsurance, such as dialysis and some medical equipment.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $300 copay for days 1-4, and no copay for days 5-90. Additional days are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, nor are Non-Medicare-covered stays for Inpatient Hospital Psychiatric.
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 $300, observation services have a $300 copay, and individual and group outpatient substance abuse sessions each have a $40 copay; all other services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Anthem Prime (HMO-POS) plan, with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Anthem Prime (HMO-POS), with prior authorization required for all ambulance services. Ground ambulance services have a $260 copay, while air ambulance services have 20% coinsurance; transportation services to health-related locations 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 all have a $90 copay.
Primary Care See details
The Anthem Prime (HMO-POS) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $15 copay, physician specialist services with a $10 copay, mental health specialty services with a $40 copay for individual and group sessions, podiatry services with a copay between $0 and $10, 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 services with a $15 copay, additional telehealth benefits with no copay, and opioid treatment program services with a $40 copay. Prior authorization and referrals may be required for some services.
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 benefits, may have a copay. Other services such as health education, in-home safety assessments, and more, are not covered.
Hearing Services See details
Hearing services are covered by Anthem Prime (HMO-POS), including hearing exams with a $10 copay, and routine hearing exams with no copay. Prescription hearing aids and OTC hearing aids are not covered, and fitting/evaluation for hearing aids is not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$10, and eyewear with no copay for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum benefit of $200 per year; upgrades are not covered. Routine eye exams are covered with no copay, once per year.
Dental Services See details
Anthem Prime (HMO-POS) covers Medicare Dental Services with a $10 copay, and Oral Exams and Prophylaxis (Cleaning) with no copay. Dental X-Rays and Fluoride Treatment are offered as optional, supplemental benefits, and Orthodontic Services and other dental services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Anthem Prime (HMO-POS). The plan has a $35 copay for Medicare Part B Insulin Drugs, and covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 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, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, are covered under the Anthem Prime (HMO-POS) plan. DME has no copay and a coinsurance between 0% and 20%, with prior authorization required, and is limited to preferred vendors. Prosthetic Devices and Medical Supplies have no copay, with 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 under the Anthem Prime (HMO-POS) plan. Diagnostic Procedures/Tests and Diagnostic Radiological Services have a coinsurance of at most 20%, while Lab Services and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Anthem Prime (HMO-POS) plan with no copay and no coinsurance. However, 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. Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Anthem Prime (HMO-POS), but require prior authorization. There is no copay for days 1-20, and a $140 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Other 1 with no copay, while 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. OTC items have a maximum plan benefit coverage amount of $10 every three months.
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