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 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 Santa Clara 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 $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:
Sign up for Anthem Prime (HMO-POS)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Anthem Prime (HMO-POS) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you may pay a coinsurance for your prescriptions. For preferred generic drugs, there is no copay at preferred, standard, and mail order pharmacies. For standard generic drugs, you pay 20% coinsurance at preferred and mail order pharmacies and 25% at standard pharmacies.
Additional Benefits
The Anthem Prime (HMO-POS) plan offers comprehensive coverage with a variety of benefits. Many services, including inpatient hospital stays, outpatient services, primary care, preventive services, vision, and dental, have no copay, making it easy to access care. This plan also covers specific services like ambulance transportation, emergency services, and hearing aids, with associated copays or coinsurance. Additional benefits like home health services, medical equipment, and skilled nursing facilities are covered, with varying costs and requirements such as prior authorization.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with no copay for Medicare-covered stays, and additional days are covered with no copay per day. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
The Anthem Prime (HMO-POS) plan covers outpatient services, including outpatient hospital services, observation services, ambulatory surgical center services, and outpatient blood services with no copay. Outpatient substance abuse services are covered with a $25 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by Anthem Prime (HMO-POS) with no copay, but 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. 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 under the Anthem Prime (HMO-POS) plan. Emergency Services and Worldwide Emergency Coverage have a $90 copay, while Urgently Needed Services have a $25 copay.
Primary Care See details
The Anthem Prime (HMO-POS) plan offers 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. Mental health specialty services, psychiatric services, and opioid treatment program services have a $25 copay for individual and group sessions.
Preventive Services See details
Preventive Services include coverage for services like annual physical exams with no copay, and also cover additional preventive services like fitness benefits, remote access technologies, and home and bathroom safety devices. Additional preventive services have varying copays, while some services such as health education, in-home safety assessments, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams and OTC hearing aids have no copay, while prescription hearing aids have a $3000 maximum plan benefit. Routine hearing exams and fitting/evaluation for hearing aids have no copay and are available once per year. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Anthem Prime (HMO-POS) plan covers vision services, including eye exams and eyewear. Eye exams and eyewear have no copay, and there is a combined maximum of $250 for eyewear every year.
Dental Services See details
The Anthem Prime (HMO-POS) plan covers a variety of dental services, including oral exams, dental x-rays, and other diagnostic and preventive services, with no copay. This plan also covers orthodontic services with a maximum benefit of $750 every year, and also covers restorative services, endodontics, periodontics, and more, with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
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 is covered by Anthem Prime (HMO-POS), including durable medical equipment with a coinsurance between 0% and 20%, prosthetics and medical supplies with a coinsurance, and diabetic equipment with no copay for diabetic supplies and therapeutic shoes/inserts. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with no copay, lab services with no copay, diagnostic radiological services with a copay up to $50, therapeutic radiological services with a copay of $50, and outpatient X-ray services with no copay. Prior authorization and a doctor referral are required for all services.
Home Health Services See details
Home Health Services are covered by Anthem Prime (HMO-POS) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization and a referral.
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. For days 1-20, there is no copay, and for days 21-100, the copay is $50.
Other Services See details
The Anthem Prime (HMO-POS) plan covers acupuncture with no copay, but requires prior authorization and is limited to 24 treatments per year. Over-the-counter items are also covered with no copay, up to a maximum of $45 every three months, and unused amounts carry over. Some Other Services are not covered, including meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved