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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 Los Angeles and Orange 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. Additionally, this plan comes with a Part B Premium reduction of $14.90. You must continue to pay paying your reduced 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
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 for your prescriptions, depending on the drug tier and where you fill your prescription. For preferred generic drugs, there is no copay at preferred and standard pharmacies, and also no copay for standard mail order. After your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers a wide range of benefits with varying costs. Many services have no copay, including inpatient hospital stays, outpatient services, primary care visits, preventive services, hearing exams, vision services, and dental services. Emergency services have a $90 copay, while urgently needed services have a $25 copay. Other services like ambulance and transportation have copays, and some services like mental health and substance abuse treatment have copays. This plan also covers home health services and skilled nursing facilities with no copay for the initial days of care. Diagnostic and radiological services, medical equipment, and dialysis services are covered with either copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, there is no copay for a Medicare-covered stay, and additional days are covered with no copay per day, but non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, observation services, and ambulatory surgical center (ASC) services have no copay, while outpatient substance abuse services have a $25 copay for both individual and group sessions. Outpatient blood services also have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Prime (HMO-POS) plan, with no copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Anthem Prime (HMO-POS), including ground and air ambulance services with a $150 copay, and transportation services to a plan-approved health-related location with no copay, up to 20 one-way trips per year. 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 by Anthem Prime (HMO-POS). Emergency Services and Worldwide Emergency Coverage have a $90 copay, while Urgently Needed Services have a $25 copay, and there is no coinsurance for any of these services. Worldwide Emergency Services has a maximum plan benefit coverage of $100,000.
Primary Care See details
The Anthem Prime (HMO-POS) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, physician specialist services, physical therapy and speech-language pathology services, and additional telehealth benefits have no copay. Individual and group sessions for mental health specialty services and psychiatric services have a $25 copay, and opioid treatment program services have a minimum and maximum copay of $25.
Preventive Services See details
Preventive Services includes coverage for annual physical exams with no copay, as well as additional preventive services, some of which may have a copay. The plan also covers fitness benefits and remote access technologies with no copay, and other services such as kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit with no copay. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
The Anthem Prime (HMO-POS) plan covers hearing exams, routine hearing exams, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $3,000 per year, and OTC hearing aids are covered with no copay up to $300 per year.
Vision Services See details
The Anthem Prime (HMO-POS) plan covers vision services, including eye exams and eyewear, with no copay. Routine eye exams are limited to one per year, while eyewear has a combined maximum benefit of $150 per year, and upgrades are not covered.
Dental Services See details
Dental Services are covered under the Anthem Prime (HMO-POS) plan, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics, all with no copay. This plan has a maximum benefit of $500 per year for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Anthem Prime (HMO-POS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by Anthem Prime (HMO-POS), with Durable Medical Equipment (DME) subject to a coinsurance between 0% and 20%, and Prosthetic Devices and Medical Supplies both subject to a 20% coinsurance, and no copay. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with no copay, Lab Services with no copay, Diagnostic Radiological Services with a copay of at most $50, Therapeutic Radiological Services with a $50 copay, and Outpatient X-Ray Services with no copay. All services require prior authorization and a doctor referral.
Home Health Services See details
Home Health Services are covered under the Anthem Prime (HMO-POS) plan with no copay and no coinsurance. 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. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Anthem Prime (HMO-POS) plan, but require prior authorization. There is no copay for days 1-20, and a $50 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include acupuncture and over-the-counter (OTC) items, with no copay for acupuncture and OTC items. Acupuncture has a limit of 24 treatments per year and requires prior authorization, while OTC items have a maximum benefit coverage amount of $50 every three months.
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