A non-government entity
Anthem Medicare Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Anthem Medicare Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Anthem Medicare Advantage (HMO) in 2026, please refer to our full plan details page.
Anthem Medicare Advantage (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2026 to people living in Select counties in CT. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Anthem Medicare Advantage (HMO) 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 Medicare Advantage (HMO).
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 Medicare Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $36.00. 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 $215.00 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 $9250.00 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 Medicare Advantage (HMO) plan features a $215 drug deductible. For Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs, you will pay no copay when using a preferred pharmacy or standard mail order. If you choose a standard pharmacy, Tier 1 copays start at $5 and Tier 2 copays start at $10, while Tier 6 select care drugs remain at no copay. For higher-tier medications, this plan transitions to coinsurance costs. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 30% coinsurance across all pharmacy options. These coinsurance rates apply to up to a three-month supply, except for Tier 5 specialty medications which are limited to a one-month supply.
Additional Benefits
The Anthem Medicare Advantage (HMO) plan offers affordable access to essential medical care with a low $5 copay for primary care visits, a $50 copay for specialists, and no copay for telehealth services. For hospital stays, members pay a $425 daily copay for the first five days of acute inpatient care and no copay for day six and beyond. Emergency room visits carry a $115 copay, while urgent care services require a $40 copay, with no coinsurance for either service. Routine vision and hearing exams are available with no copay, including up to $175 annually for eyewear and up to $2,000 for prescription hearing aids, though routine dental care is not covered. Home health services and diabetic supplies are fully covered with no copay, while durable medical equipment and dialysis require coinsurance of up to 20%. Skilled nursing facility stays are covered with no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
Anthem Medicare Advantage (HMO) partially covers inpatient hospital services with no coinsurance, though upgrades and non-Medicare-covered stays are not covered. For acute inpatient stays, there is a $425 copay per day for days 1 through 5 and no copay for days 6 and beyond, while psychiatric stays require a $415 copay per day for days 1 through 5 and no copay thereafter.
Outpatient Services See details
Anthem Medicare Advantage (HMO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of up to $425, including a $425 copay per stay for observation services, while outpatient substance abuse sessions carry a $40 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Anthem Medicare Advantage (HMO) with a $40.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered under Anthem Medicare Advantage (HMO); ground and air ambulance services require prior authorization and a $285 copay with no coinsurance, while transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Anthem Medicare Advantage (HMO) covers emergency services with a $115 copay and no coinsurance, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $100,000 maximum limit with a $115 copay and no coinsurance per service.
Primary Care See details
Anthem Medicare Advantage (HMO) covers primary care visits for a $5.00 copay and specialist visits for a $50.00 copay, both with no coinsurance. Telehealth services feature no copay and no coinsurance, while covered mental health, physical, occupational, and speech therapies require copays ranging from $35.00 to $40.00 with no coinsurance, though podiatry and chiropractic services are not covered.
Preventive Services See details
Anthem Medicare Advantage (HMO) preventive services are partially covered with no copay and no coinsurance for covered services, including annual physical exams, remote access technologies, kidney disease education, glaucoma screenings, and diabetes self-management training. However, several additional services are not covered, such as fitness benefits, health education, in-home safety assessments, personal emergency response systems, weight management programs, and nutritional/dietary benefits.
Hearing Services See details
Anthem Medicare Advantage (HMO) covers Medicare-covered hearing exams with a $50 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. OTC hearing aids are covered up to $300 annually with no copay and no coinsurance, and prescription hearing aids are partially covered up to $2,000 annually with no copay and no coinsurance, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Anthem Medicare Advantage (HMO) vision services are partially covered, offering routine eye exams and eyewear like contact lenses and eyeglasses with no copay, no coinsurance, and a $175 annual limit. Other eye exam services and eyewear upgrades are not covered, though covered eye exams may carry a copay of $0 to $50 with no coinsurance.
Dental Services See details
Dental services are partially covered by the Anthem Medicare Advantage (HMO) plan, which offers Medicare-covered dental services with no copay and no coinsurance, though prior authorization is required. However, routine and comprehensive services—including oral exams, cleanings, x-rays, fluoride treatments, restorative services, and orthodontics—are not covered.
Home Infusion bundled Services See details
Anthem Medicare Advantage (HMO) covers home infusion bundled services with no copay, although prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Anthem Medicare Advantage (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Anthem Medicare Advantage (HMO) covers durable medical equipment with no copay and 0% to 20% coinsurance, and prosthetic devices and medical supplies with no copay and 20% coinsurance. Diabetic equipment, supplies, and therapeutic shoes or inserts are covered with no copay and no coinsurance, subject to manufacturer limitations.
Diagnostic and Radiological Services See details
Anthem Medicare Advantage (HMO) covers diagnostic and radiological services, with prior authorization required. Diagnostic tests have no coinsurance and a $0 to $70 copay, lab services have no copay or coinsurance, and radiological services require a $25 copay plus coinsurance for X-rays, a minimum $50 copay for diagnostic radiology, and a minimum 20% coinsurance plus copay for therapeutic radiology.
Home Health Services See details
Home health services are covered under the Anthem Medicare Advantage (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Anthem Medicare Advantage (HMO) with no coinsurance, although prior authorization is required. While some services are covered, specific sub-services including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered in practice.
Skilled Nursing Facility (SNF) See details
Anthem Medicare Advantage (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Anthem Medicare Advantage (HMO) covers some other services, although specific benefits such as acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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