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 2025 to people living in Rockland and Westchester Counties. 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 $65.00. 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 $200.00 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 drug deductible of $200 before coverage begins for higher-tier medications. Tier 1 preferred generic drugs have no copay for up to a three-month supply at preferred pharmacies, standard pharmacies, and through standard mail order. Tier 2 generic drugs also offer no copay at preferred pharmacies and through standard mail order, while standard pharmacies charge a $10 copay for a one-month supply. For brand-name and specialty medications, the plan utilizes coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 30% coinsurance. These coinsurance rates apply to preferred pharmacies, standard pharmacies, and standard mail-order options, with specialty tier prescriptions limited to a one-month supply.
Additional Benefits
The Anthem Medicare Advantage (HMO) plan offers affordable coverage for essential medical needs, featuring a $10 copay for primary care visits and no copay for telehealth services. Specialist visits require a $50 copay, while inpatient hospital stays cost a $385 copay for the first 5 to 6 days with no copay for additional days. Emergency care is accessible with a $115 copay, and urgent care visits require a $40 copay, both with no coinsurance. This plan also includes no copays for home health services, routine eye exams, and routine hearing exams, though routine dental services are not covered. Prescription hearing aids are covered up to a $3,000 annual limit with no copay, and eyewear is covered up to a $150 yearly limit with no copay. Additionally, diagnostic lab services and diabetic supplies are available with no copay, while durable medical equipment incurs a 0% to 20% coinsurance.
Inpatient Hospital See details
Anthem Medicare Advantage (HMO) covers inpatient hospital services with no coinsurance, requiring a $385 copay for days 1 through 6 of acute stays and days 1 through 5 of psychiatric stays, with no copay for additional days. Prior authorization is required, and non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Anthem Medicare Advantage (HMO) covers outpatient hospital services with no copay and 25% coinsurance, and ambulatory surgical center services with no copay and 20% coinsurance. Outpatient substance abuse services require a $50 copay per session with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Anthem Medicare Advantage (HMO) covers partial hospitalization services with a $40.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Anthem Medicare Advantage (HMO) covers Medicare-covered ground and air ambulance services with a $289 copay and no coinsurance, though prior authorization is required. While some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Anthem Medicare Advantage (HMO) covers emergency services with a $115 copay and urgently needed services with a $40 copay, both with 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.
Primary Care See details
Anthem Medicare Advantage (HMO) covers primary care visits with a $10 copay, specialist visits with a $50 copay, and telehealth services with no copay, all with no coinsurance. Other covered benefits, including physical, occupational, and mental health therapies, require copays ranging from $10 to $50 and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Anthem Medicare Advantage (HMO) offers preventive services that are partially covered, featuring no copay and no coinsurance for covered benefits like annual physical exams, remote access technologies, and kidney disease education. However, several sub-services are not covered, including fitness benefits, health education, in-home safety assessments, and nutritional or dietary benefits.
Hearing Services See details
Anthem Medicare Advantage (HMO) covers Medicare-covered hearing exams for a $50 copay and no coinsurance, while routine exams, fittings, and OTC hearing aids (up to $300 annually) require prior authorization but have no copay and no coinsurance. Prescription hearing aids also require prior authorization and are partially covered with no copay and no coinsurance up to a $3,000 annual limit, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Anthem Medicare Advantage (HMO), featuring no coinsurance and no copays for annual routine eye exams and covered eyewear up to a $150 yearly limit. Other eye exam services and upgrades are not covered, and prior authorization is required for eye exams.
Dental Services See details
Anthem Medicare Advantage (HMO) partially covers dental services, offering Medicare-covered dental care with no copay and no coinsurance, although prior authorization is required. Routine and comprehensive dental services, including oral exams, cleanings, x-rays, fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, and oral surgery, are not covered.
Home Infusion bundled Services See details
Anthem Medicare Advantage (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy may apply. Covered Medicare Part B chemotherapy and other drugs require no copay and a 0% to 20% coinsurance, while Part B insulin is available for a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Anthem Medicare Advantage (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered by Anthem Medicare Advantage (HMO) with no copays, though prior authorization and coinsurance may apply depending on the item. Durable medical equipment incurs 0% to 20% coinsurance, prosthetics and medical supplies require 20% coinsurance, and diabetic supplies are fully covered with no coinsurance.
Diagnostic and Radiological Services See details
Anthem Medicare Advantage (HMO) covers diagnostic services with no coinsurance, offering no copay for lab services and a $0 to $110 copay for diagnostic procedures. Radiological services are also covered, featuring a $45 copay for outpatient X-rays, a minimum $45 copay for diagnostic radiological services, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Anthem Medicare Advantage (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Anthem Medicare Advantage (HMO) covers Cardiac Rehabilitation Services with no copay and no coinsurance, though prior authorization is required. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Anthem Medicare Advantage (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are covered by Anthem Medicare Advantage (HMO), meaning some services are covered, but acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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