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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 Los Angeles and Orange 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 $499.00 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
Anthem Prime (HMO-POS) offers an Enhanced Alternative drug benefit with no prescription drug deductible. For Tier 1 preferred generic drugs, members pay no copay at preferred, standard, and standard mail pharmacies. Tier 2 standard generic drugs require a $42 copay at preferred and standard mail pharmacies, or a $47 copay at standard pharmacies. For higher-tier medications, Tier 3 preferred brand drugs carry a 25 percent coinsurance, while Tier 4 non-preferred drugs require a 33 percent coinsurance. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. This plan also offers drug premium reductions down to $0 for individuals who qualify for the low-income subsidy.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care, specialist visits, inpatient hospital stays, and outpatient services. If you need emergency care, you can expect a $150 copay, which is waived if you are admitted, while urgently needed services require a $25 copay. Additionally, diagnostic procedures, laboratory tests, and outpatient X-rays are fully covered with no copay or coinsurance. For routine care, the plan features no copay for annual physicals, routine eye exams, and preventive dental services, though comprehensive dental services require a 25% coinsurance. You also receive coverage for hearing exams and prescription hearing aids up to a $3,000 annual limit with no copay. Durable medical equipment and prosthetics are covered with no copay and coinsurance ranging up to 20%.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Anthem Prime (HMO-POS), featuring Medicare-covered acute and psychiatric stays with no copay or coinsurance. While unlimited additional days are covered with no copay or coinsurance, prior authorization is required, and upgrades as well as 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 outpatient hospital, observation, ambulatory surgical center, and blood services. A $25 copay applies to both individual and group outpatient substance abuse sessions.
Partial Hospitalization See details
Partial hospitalization benefits are covered by Anthem Prime (HMO-POS) with no copay and no coinsurance. Prior authorization is required to access these services.
Ambulance and Transportation Services See details
Anthem Prime (HMO-POS) partially covers ambulance and transportation services, as transportation to any health-related location is not covered. Covered ground and air ambulance services require a $175 copay and no coinsurance, while up to two one-way trips per year to plan-approved locations are covered with no copay and no coinsurance.
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 require a $25 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 limit with a $150 copay and no coinsurance.
Primary Care See details
Anthem Prime (HMO-POS) covers primary care, specialist, therapy, telehealth, podiatry, and chiropractic services with no copay and no coinsurance. Mental health, psychiatric, and opioid treatment services are also covered under the plan for a $25 copay and no coinsurance.
Preventive Services See details
Anthem Prime (HMO-POS) offers partially covered preventive services with no copay and no coinsurance for covered benefits like annual physicals, kidney disease education, and select screenings. However, several sub-services are not covered, including fitness benefits, weight management, health education, alternative therapies, therapeutic massage, personal emergency response systems, and counseling.
Hearing Services See details
Anthem Prime (HMO-POS) offers hearing services with no copay and no coinsurance for routine exams, fitting evaluations, and OTC hearing aids up to a $300 annual limit. Prescription hearing aids are partially covered up to a $3,000 annual limit with no copay or coinsurance, though inner ear, outer ear, and over-the-ear devices are not covered.
Vision Services See details
Anthem Prime (HMO-POS) covers vision services with no copay or coinsurance for one routine eye exam per year and eligible eyewear, though upgrades are not covered. There is no deductible, and the plan includes a combined maximum eyewear coverage of $75 annually for contacts, frames, and lenses.
Dental Services See details
Dental services are partially covered by Anthem Prime (HMO-POS) with a $200 annual maximum, though maxillofacial prosthetics, implant services, and orthodontics are not covered. Diagnostic and preventive services require no copay and no coinsurance, while covered comprehensive services have a 25% coinsurance and no copay.
Home Infusion bundled Services See details
Anthem Prime (HMO-POS) covers Home Infusion bundled Services with prior authorization and step therapy, featuring a $35 copay and no coinsurance for Part B insulin drugs. Chemotherapy, radiation, and other Part B drugs are covered with no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered by Anthem Prime (HMO-POS) with no copay and a 20% coinsurance.
Medical Equipment See details
Anthem Prime (HMO-POS) covers medical equipment, including durable medical equipment (DME) with no copay and 0% to 20% coinsurance, and prosthetics and medical supplies with no copay and 20% coinsurance. Diabetic supplies and therapeutic shoes or inserts are also covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Anthem Prime (HMO-POS) covers diagnostic and radiological services, requiring a doctor referral and prior authorization for these benefits. Diagnostic procedures, lab services, and outpatient X-rays are offered with no copay and no coinsurance, while diagnostic radiological services have a copay of up to $50 with no coinsurance, and therapeutic radiological services require 20% coinsurance with no copay.
Home Health Services See details
Anthem Prime (HMO-POS) covers home health services with no copay and no coinsurance. Prior authorization and a doctor referral are required to access this benefit.
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 SET for PAD rehabilitation services, which are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Anthem Prime (HMO-POS), requiring prior authorization and featuring no copay for days 1 to 20, a $218 daily copay for days 21 to 100, and no coinsurance. Additional days beyond the Medicare-covered limit are not covered under this plan.
Other Services See details
Anthem Prime (HMO-POS) partially covers other services with no copay and no coinsurance, including acupuncture up to 24 treatments per year and a $50 quarterly over-the-counter allowance. Meal benefits and dual eligible SNPs with highly integrated services are not covered under this plan.
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