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 Nassau County. 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 $80.00. 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:
Sign up for Anthem Medicare Advantage (HMO)
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Drug Coverage
The Anthem Medicare Advantage (HMO) plan features a $200 drug deductible and offers competitive cost-sharing options for generic medications. For Tier 1 preferred generic drugs, you will pay no copay for a one, two, or three-month supply at preferred pharmacies, standard pharmacies, and standard mail order. Tier 2 generic drugs also feature no copay at preferred pharmacies and standard mail order, while standard pharmacies charge a copay of $5 for a one-month supply, $10 for a two-month supply, and $15 for a three-month supply. Brand-name and specialty medications under this plan require coinsurance rather than a flat copayment. Tier 3 preferred brand drugs have a 25% coinsurance for all supply durations at preferred, standard, and standard mail-order pharmacies. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require 30% coinsurance, with specialty drugs limited to a one-month supply.
Additional Benefits
The Anthem Medicare Advantage (HMO) plan offers affordable healthcare coverage featuring no copays for primary care visits, annual physicals, and home health services. For emergency room visits, members pay a $115 copay, while inpatient hospital stays require a $400 daily copay for the first few days and no copay for subsequent days. Most of these core medical services, including outpatient surgeries and diagnostic laboratory tests, are covered with no coinsurance. Specialty care benefits include routine vision and hearing exams with no copay, alongside allowances for eyewear and hearing aids. While Medicare-qualified dental services and cardiac rehabilitation feature no copay, routine dental care and common fitness benefits are not covered by this plan. For medical equipment and specialized treatments like dialysis or chemotherapy, members can expect no copay and a coinsurance ranging from 0% to 20%.
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. Patients pay a $400 daily copay for days 1 to 6 of acute stays and days 1 to 5 of psychiatric stays, with no copay required for additional days.
Outpatient Services See details
Anthem Medicare Advantage (HMO) covers outpatient services with no coinsurance, offering no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital service copays range from $0 to $400, while observation services cost a $400 copay per stay and outpatient substance abuse sessions require a $55 copay.
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 access this covered benefit.
Ambulance and Transportation Services See details
Anthem Medicare Advantage (HMO) covers ground and air ambulance services with a $325 copay and no coinsurance, subject to prior authorization. For transportation benefits, some services are covered but transportation to plan-approved or 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 benefit with a $115 copay and no coinsurance.
Primary Care See details
Anthem Medicare Advantage (HMO) covers primary care and telehealth services with no coinsurance and copays ranging from no copay to $15. Other services like specialists, therapies, mental health, and psychiatric care have no coinsurance and copays between $35 and $55, while podiatry and chiropractic services are not covered.
Preventive Services See details
Anthem Medicare Advantage (HMO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and screenings like glaucoma and diabetes self-management. However, additional preventive services are only partially covered; remote access technologies are covered with no copay, but fitness benefits, health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, caregiver support, smoking cessation, disease management, telemonitoring, home safety modifications, and counseling are not covered.
Hearing Services See details
Anthem Medicare Advantage (HMO) hearing services require prior authorization and include annual routine exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams have a $55 copay and no coinsurance. Prescription hearing aids are partially covered up to a $2,000 yearly limit with no copay or coinsurance, though inner ear, outer ear, and over the ear types are not covered. Over-the-counter (OTC) hearing aids are also covered up to $300 annually with no copay and no coinsurance.
Vision Services See details
Anthem Medicare Advantage (HMO) provides partially covered vision services with no coinsurance, offering no copay for one annual routine eye exam and eyewear up to a $125 yearly limit. Other eye exam services and eyewear upgrades are not covered, and certain covered eye exams require prior authorization and a copay of up to $55.
Dental Services See details
Anthem Medicare Advantage (HMO) covers Medicare-qualified dental services with no copay and no coinsurance, although prior authorization is required. Routine and comprehensive dental services, including exams, cleanings, x-rays, and restorative care, are not covered under this plan.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Anthem Medicare Advantage (HMO) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance of 0% to 20%.
Dialysis Services See details
Anthem Medicare Advantage (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Anthem Medicare Advantage (HMO) covers durable medical equipment (DME) with no copay and 0% to 20% coinsurance, subject to prior authorization and preferred vendor rules. Prosthetics and medical supplies are covered with no copay and 20% coinsurance, while diabetic supplies and shoes feature no copay and no coinsurance from specified manufacturers.
Diagnostic and Radiological Services See details
Anthem Medicare Advantage (HMO) covers diagnostic services with no coinsurance, featuring a $0 to $150 copay for procedures and no copay for lab services. Covered radiological services require a minimum $45 copay for diagnostic radiology, a $45 copay for outpatient X-rays, and a minimum 20% coinsurance for therapeutic radiology, with prior authorization required for all services.
Home Health Services See details
Home health services are covered by Anthem Medicare Advantage (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Anthem Medicare Advantage (HMO) covers Cardiac Rehabilitation Services with no copay and no coinsurance, although prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation 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 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) partially covers other services, featuring a chronic illness meal benefit with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered.
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