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 2025, 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 New York City Area. This plan received an overall rating of 3 out of 5 stars in 2025.
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 $24.00. 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 $350.00 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 $8900.00 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 has a $350 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $15 copay at preferred pharmacies and 20% coinsurance at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. This plan also offers a premium reduction for those who qualify for the low-income subsidy, with a monthly Part D premium of $24.
Additional Benefits
The Anthem Medicare Advantage (HMO) plan offers coverage for a variety of services with varying costs. Inpatient hospital stays have a copay of $480 for days 1-4, with no copay for days 5-90. Outpatient services have coinsurance or copays depending on the service, while emergency services have copays between $45 and $110. This plan covers primary care with a $10 copay, and also offers coverage for preventive services, hearing exams, vision exams, and certain dental services. Additionally, the plan covers ambulance services, home health services with no copay, and medical equipment with coinsurance, along with diagnostic, radiological, and dialysis services. Other benefits include Over-the-Counter (OTC) items with no copay, and coverage for nicotine replacement therapy and naloxone.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by the Anthem Medicare Advantage (HMO) plan, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For days 1-4 of an inpatient stay, the copay is $480, and there is no copay for days 5-90. Additional days for Inpatient Hospital-Acute and Psychiatric are covered with no copay. 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
Outpatient Services include coverage for all outpatient hospital services with a 30% coinsurance and no copay, observation services with a 30% coinsurance and a copay, and Ambulatory Surgical Center (ASC) Services with a 20% coinsurance and no copay. Outpatient Substance Abuse Services have a $40 copay for both individual and group sessions. Outpatient Blood Services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Anthem Medicare Advantage (HMO) plan, but requires prior authorization. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Anthem Medicare Advantage (HMO) plan. Ground ambulance services have a $265 copay, while air ambulance services have a 20% coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, and Worldwide Emergency Services are covered. For Emergency Services and Worldwide Emergency Coverage, the copay is $110, and for Urgently Needed Services, the copay is $45; all have no coinsurance.
Primary Care See details
The Anthem Medicare Advantage (HMO) plan covers primary care physician services with a $10 copay, chiropractic services with a $15 copay, and occupational therapy services with a $35 copay. Mental health and psychiatric services have a $40 copay for individual and group sessions, and physical therapy and speech-language pathology services have a $40 copay. Additional telehealth benefits have no copay, while Opioid Treatment Program Services have a $40 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for services like an annual physical exam with no copay, and additional preventive services. Additional preventive services have a copay, and some services like health education and in-home safety assessments are not covered.
Hearing Services See details
Hearing Services are partially covered under the Anthem Medicare Advantage (HMO) plan, with a $50 copay for hearing exams, but routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams, with a copay between $0 and $50 depending on the exam, and routine eye exams with no copay. Eyewear is covered, but Contact Lenses, Eyeglasses (lenses and frames), Eyeglass lenses, Eyeglass frames, and Upgrades are not covered.
Dental Services See details
Dental Services are partially covered under the Anthem Medicare Advantage (HMO) plan. Medicare Dental Services are covered with no copay, but Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. Medicare Part B insulin drugs have a $35 copay, and coinsurance applies for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Anthem Medicare Advantage (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by Anthem Medicare Advantage (HMO), including durable medical equipment (DME) with 0% to 20% coinsurance and no copay. The plan also covers prosthetics and medical supplies with a 20% coinsurance, and diabetic equipment with no copay for diabetic supplies and therapeutic shoes/inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a copay between $0 and $150, and lab services with no copay. Radiological services are covered, including diagnostic radiological services with a copay between $55 and $250, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $55 copay.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Anthem Medicare Advantage (HMO) plan, but none of the sub-services are covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Anthem Medicare Advantage (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items with no copay, a maximum plan benefit coverage amount of $30 every three months, and includes Nicotine Replacement Therapy (NRT) and Naloxone coverage. Other services such as acupuncture, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and more are not covered.
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