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 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 Santa Clara 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $800.00 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 prescription drug plan with no drug deductible, allowing your coverage to start immediately. During the initial coverage phase, there is no copay for Tier 1 preferred generic drugs at preferred pharmacies, standard pharmacies, or through standard mail. For Tier 2 standard generic drugs, you will pay a $42 copay at preferred pharmacies and standard mail, or a $47 copay at standard pharmacies. For higher-tier medications, Tier 3 preferred brand drugs require 25% coinsurance and Tier 4 non-preferred drugs require 33% 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.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers robust coverage with no copay and no coinsurance for many essential medical services, including inpatient hospital stays, primary care visits, specialist consultations, and home health services. Outpatient hospital services and preventive care are also covered with no copay, while emergency room visits require a $150 copay that is waived if you are admitted. Ambulance services incur a $200 copay, but the plan covers up to 36 one-way transportation trips per year to approved health locations with no copay. For supplemental care, the plan features no copay for routine vision and hearing exams, providing a $300 annual allowance for eyewear and up to a $3,000 annual limit for prescription hearing aids. Dental care is covered up to $500 annually, offering diagnostic services with no copay and comprehensive care at a 25% coinsurance. Additionally, members benefit from acupuncture and an over-the-counter allowance of $38 every three months with no copay.
Inpatient Hospital See details
Anthem Prime (HMO-POS) provides partially covered inpatient hospital benefits, offering Medicare-covered acute and psychiatric stays with no copay and no coinsurance. While unlimited additional days are covered at no cost, upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Anthem Prime (HMO-POS), offering no copay and no coinsurance for outpatient hospital, observation, ambulatory surgical center, and blood services. Outpatient substance abuse services are also covered with a $25 copay and no coinsurance for individual and group sessions.
Partial Hospitalization See details
Partial hospitalization benefits are covered under Anthem Prime (HMO-POS) with no copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Anthem Prime (HMO-POS) partially covers ambulance and transportation services, requiring a $200 copay and no coinsurance for ground and air ambulance services. Transportation to plan-approved health-related locations is covered for up to 36 one-way trips per year with no copay and no coinsurance, while transportation to any health-related location is 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 are covered with a $25 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $100,000 maximum with a $150 copay and no coinsurance.
Primary Care See details
Anthem Prime (HMO-POS) provides primary care, specialist, therapy, telehealth, chiropractic, and podiatry services with no copay and no coinsurance. Covered mental health, psychiatric, and opioid treatment services require a $25 copay and no coinsurance.
Preventive Services See details
Anthem Prime (HMO-POS) partially covers preventive services with no copay and no coinsurance for covered benefits like annual physicals, kidney disease education, and glaucoma screenings. However, sub-services such as fitness benefits, health education, weight management, alternative therapies, counseling, PERS, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, safety assessments, telemonitoring, and post-discharge medication reconciliation are not covered.
Hearing Services See details
Hearing services are covered by Anthem Prime (HMO-POS) with no copay and no coinsurance for exams, fitting evaluations, and OTC hearing aids up to a $300 annual limit. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $3,000 annual limit, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Anthem Prime (HMO-POS) partially covers vision services with no copay and no coinsurance, though upgrades are not covered. Covered benefits include one routine eye exam per year and a $300 annual allowance for eyewear, including contact lenses, eyeglass lenses, and frames.
Dental Services See details
Dental services are partially covered by Anthem Prime (HMO-POS) up to a $500 annual maximum, featuring no copay and no coinsurance for diagnostic and preventive care, and a 25% coinsurance with no copay for comprehensive services. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Anthem Prime (HMO-POS) covers Home Infusion bundled Services with prior authorization required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis Services are covered by Anthem Prime (HMO-POS) with a 20% coinsurance and no copay.
Medical Equipment See details
Anthem Prime (HMO-POS) covers medical equipment, including durable medical equipment (DME) with no coinsurance to 20% coinsurance, and prosthetic devices and medical supplies with a 20% coinsurance and no copay. Diabetic supplies and therapeutic shoes or inserts are covered with no copay, though prior authorization is required for DME and prosthetics.
Diagnostic and Radiological Services See details
Anthem Prime (HMO-POS) covers diagnostic and radiological services with prior authorization and a doctor referral. There is no copay or coinsurance for diagnostic procedures, lab services, and outpatient X-rays, while diagnostic radiological services have a copay of up to $50 and therapeutic radiological services require a 20% coinsurance.
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 receive these covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Anthem Prime (HMO-POS) plan. There is no coverage, copay, or coinsurance for cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, or SET for PAD services.
Skilled Nursing Facility (SNF) See details
Anthem Prime (HMO-POS) partially covers Skilled Nursing Facility (SNF) services, though additional days beyond Medicare-covered stays are not covered and prior authorization is required. For covered stays, there is no copay and no coinsurance for days 1 through 20, followed by a $218 daily copay and no coinsurance for days 21 through 100.
Other Services See details
Other Services are partially covered under Anthem Prime (HMO-POS), with acupuncture, over-the-counter (OTC) items, and community resource support available with no copay and no coinsurance, while meal benefits and integrated SNP services are not covered. Covered acupuncture is limited to 24 treatments per year, and OTC items have a maximum allowance of $38 every three months.
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