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 Suffolk 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 $90.00. 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 $100.00 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 $100 drug deductible before coverage begins. For Tier 1 preferred generic drugs, you will pay no copay for one-month, two-month, or three-month supplies at preferred, standard, and standard mail-order pharmacies. Tier 2 generic drugs also feature no copay at preferred pharmacies and 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 copays. Tier 3 preferred brand drugs require a 25% coinsurance, and Tier 4 non-preferred drugs carry a 30% coinsurance. Tier 5 specialty drugs require a 31% coinsurance for a one-month supply across preferred, standard, and standard mail-order options.
Additional Benefits
The Anthem Medicare Advantage (HMO) plan offers affordable access to essential medical services, featuring no copay for telehealth and annual physicals, a $15 copay for primary care visits, and a $55 copay for specialists. Inpatient hospital stays require a $410 daily copay for the first few days with no copay thereafter, while emergency room visits carry a flat $115 copay. Preventive care is fully covered with no copays or coinsurance, helping you manage your health proactively. For specialized care, the plan provides routine vision and hearing exams with no copay, including allowances of up to $200 for eyewear and $2,000 for prescription hearing aids. Many other services, such as home health care, diabetic supplies, and Medicare-covered dental care, are also available with no copay or coinsurance. However, some services like dialysis and durable medical equipment will require a coinsurance of up to 20 percent.
Inpatient Hospital See details
Anthem Medicare Advantage (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $410 daily copay for days 1 through 5 for acute stays and days 1 through 4 for psychiatric stays, with no copay for subsequent days. Prior authorization is required, and upgrades as well as non-Medicare-covered stays are not covered.
Outpatient Services See details
Anthem Medicare Advantage (HMO) outpatient services include outpatient hospital care with a 25% coinsurance and no copay, and ambulatory surgical center services with a 20% coinsurance and no copay. Additionally, outpatient substance abuse services carry a $55 copay per session with no coinsurance, while outpatient blood services are fully 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 access this benefit.
Ambulance and Transportation Services See details
Anthem Medicare Advantage (HMO) covers ground and air ambulance services with a $325.00 copay and no coinsurance, subject to prior authorization. Some transportation services are covered, but transportation to plan-approved or any health-related locations is 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, requiring a $115 copay and no coinsurance per service.
Primary Care See details
Anthem Medicare Advantage (HMO) covers primary care physician visits for a $15 copay and specialist visits for a $55 copay, both with no coinsurance. Therapy services require a $35 copay, telehealth has no copay, and mental health, psychiatric, or opioid treatments range from a $50 to $55 copay with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Anthem Medicare Advantage (HMO) covers preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. Additional preventive services are partially covered, offering remote access technologies with no copay and no coinsurance, while fitness, health education, PERS, in-home safety, medical nutrition, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, home safety devices, and counseling services are not covered.
Hearing Services See details
Anthem Medicare Advantage (HMO) covers Medicare-covered hearing exams with a $55 copay and no coinsurance, while annual routine exams and fitting evaluations have no copay or coinsurance. Hearing aids are partially covered with no copay or coinsurance, providing up to $2,000 annually for prescription hearing aids and $300 annually for OTC hearing aids, though inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by Anthem Medicare Advantage (HMO) with no coinsurance and no copays for one annual routine eye exam and eyewear, which features a $200 yearly maximum allowance. Other eye exam services and eyewear upgrades are not covered, and prior authorization is required for some eye exams.
Dental Services See details
Anthem Medicare Advantage (HMO) provides partial coverage for dental services, offering Medicare-covered dental care with no copay and no coinsurance, though prior authorization is required. Other dental services are not covered, including preventive care like oral exams, cleanings, x-rays, and fluoride, as well as restorative and orthodontic services.
Home Infusion bundled Services See details
Anthem Medicare Advantage (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Part B insulin has a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by Anthem Medicare Advantage (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Anthem Medicare Advantage (HMO) covers medical equipment, offering durable medical equipment with no copay and 0% to 20% coinsurance, alongside prosthetics and medical supplies with no copay and 20% coinsurance. Diabetic supplies and therapeutic shoes are also covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Anthem Medicare Advantage (HMO) covers diagnostic services with no coinsurance, offering lab services with no copay and diagnostic tests with a $0 to $150 copay. Radiological services require prior authorization and feature a minimum $40 copay with no coinsurance for diagnostic radiology, a $40 copay plus coinsurance for X-rays, and a minimum 20% coinsurance with a copay for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by Anthem Medicare Advantage (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Anthem Medicare Advantage (HMO) with no coinsurance and prior authorization required. Some services are covered, but standard cardiac, intensive cardiac, pulmonary, 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 daily copay of $218 for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Anthem Medicare Advantage (HMO) plan, as supplemental benefits such as acupuncture, over-the-counter (OTC) items, and meal benefits are not included.
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