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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 Ventura County. 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 $255.00 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 $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 features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $255.00. During the initial coverage phase, you will have no copay for Tier 1 preferred generic drugs filled at preferred pharmacies or through standard mail, though standard pharmacies charge a $10.00 copay. For Tier 2 standard generics, you will pay a 25% coinsurance, while Tier 3 preferred brands and Tier 4 non-preferred drugs both require a 30% coinsurance. After your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D prescriptions. Additionally, individuals who qualify for the low-income subsidy can benefit from a reduced Part D premium of $0.00. This plan provides structured copayments and coinsurance options to help manage your medication expenses throughout the year.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers comprehensive medical coverage featuring no copay for primary care visits, telehealth, and annual preventive exams. For acute care, members pay a $300 daily copay for the first four days of inpatient hospital stays, while emergency room visits require a $150 copay. Specialist visits and home health services are highly accessible, with specialist copays ranging from $10 to $40 and no copay for home health care. In addition to medical care, the plan provides valuable dental, vision, and hearing benefits with no copay for routine cleanings, annual eye exams, and hearing tests. Members also benefit from a $250 annual eyewear allowance, up to $3,000 for prescription hearing aids, and a $32 quarterly allowance for over-the-counter items. While durable medical equipment and diagnostic services may require prior authorization, they feature low costs ranging from no copay up to 20% coinsurance.
Inpatient Hospital See details
Anthem Prime (HMO-POS) partially covers inpatient hospital services, requiring a $300 daily copay for days 1 through 4, no copay for days 5 through 90, and no coinsurance for covered acute and psychiatric stays. Upgrades and non-Medicare-covered stays are not covered under this benefit.
Outpatient Services See details
Anthem Prime (HMO-POS) covers outpatient services with no coinsurance and copays ranging from no copay for blood and ambulatory surgical center services up to $300 for outpatient hospital and observation stays. Outpatient substance abuse sessions have a $40 copay, and most of these 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 for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Anthem Prime (HMO-POS), with covered ground and air ambulance services requiring a $285 copay and no coinsurance. Prior authorization is required for ambulance services, while 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 maximum with a $150 copay and no coinsurance.
Primary Care See details
Anthem Prime (HMO-POS) covers primary care physician visits and telehealth services with no copay and no coinsurance. Other covered services, such as specialist visits, physical therapy, and mental health sessions, require copays ranging from $10 to $40 with no coinsurance, while chiropractic services are only partially covered since routine chiropractic care is not covered.
Preventive Services See details
Anthem Prime (HMO-POS) covers preventive services with no copay and no coinsurance for services such as annual physical exams, remote access technologies, and kidney disease education. This benefit is only partially covered, as supplemental services like fitness benefits, health education, weight management programs, and counseling services are not covered.
Hearing Services See details
Anthem Prime (HMO-POS) covers hearing exams with a $10 copay and no coinsurance, while routine exams, fitting evaluations, and OTC hearing aids up to $300 annually have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to $3,000 annually, excluding inner ear, outer ear, and over-the-ear types.
Vision Services See details
Anthem Prime (HMO-POS) provides partially covered vision services, excluding eyewear upgrades. Covered benefits feature a $0 to $10 copay for eye exams, no copay for one annual routine exam and eligible eyewear up to a $250 yearly limit, with no coinsurance or deductibles.
Dental Services See details
Anthem Prime (HMO-POS) provides partially covered dental services, featuring Medicare-covered dental care for a $10 copay and no coinsurance, alongside annual oral exams and cleanings with no copay and no coinsurance. However, several services are not covered, including restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics.
Home Infusion bundled Services See details
Anthem Prime (HMO-POS) covers Home Infusion bundled Services, which require prior authorization and step therapy. Covered Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Anthem Prime (HMO-POS) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Anthem Prime (HMO-POS) covers medical equipment, featuring no copays or coinsurance for diabetic supplies and therapeutic shoes. Durable medical equipment requires prior authorization with no copay and 0% to 20% coinsurance, while prosthetics and medical supplies have no copay and 20% coinsurance.
Diagnostic and Radiological Services See details
Anthem Prime (HMO-POS) covers diagnostic and radiological services, which require prior authorization and doctor referrals. Diagnostic tests, procedures, and radiological services incur a 20% coinsurance and no copay, while lab and outpatient X-ray services are provided with no copay and no coinsurance.
Home Health Services See details
Home Health Services are covered under the Anthem Prime (HMO-POS) plan with no copay and no coinsurance. Prior authorization and a doctor referral are required to receive this care.
Cardiac Rehabilitation Services See details
Anthem Prime (HMO-POS) indicates some services are covered for Cardiac Rehabilitation Services with copays that vary and no coinsurance, though prior authorization is required. However, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Anthem Prime (HMO-POS) covers Skilled Nursing Facility (SNF) services with no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with no coinsurance. This benefit is partially covered because additional days beyond the Medicare-covered limit are not covered, and prior authorization is required.
Other Services See details
Other Services are partially covered under the Anthem Prime (HMO-POS) plan, offering Over-the-Counter (OTC) items with a $32 quarterly allowance and Medicare Community Resource Support with no copay and no coinsurance. Acupuncture, meal benefits, and dual eligible SNPs with highly integrated services are not covered.
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