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Anthem BlueCross BlueShield

Anthem HealthKeepers Bronze X 5500

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $5,500.00
  • Family: $11,000
  • Per Person: $5,500
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700.00
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $40.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Copay is for office visit only, other services provided during the visit are subject to deductible and coinsurance. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered.
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Specialists Visits, Mental Health and Substance Use Office Visits apply deductible/coinsurance. Copays do not apply to these services. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application, website, or HealthKeepers enabled device.

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.
Generic Drugs
  • CoPay: Not Applicable
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: 30 day supply. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: This benefit is for the hospital stay. In-Network Tier 2 cost shares only apply if services are billed by hospitals or facilities that are considered Tier 2 providers. Services billed by other providers are at the Tier 1 level.
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 35.00% Coinsurance after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Visit(s) per Benefit Period
  • Benefit Explanation: Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes. Limited to 1 visit per year.

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 2
  • Limit Unit : Visit(s) per Year
  • Benefit Explanation: Limited to 2 visits per year.
Routine Dental Checkups for Adults
  • Covered: Not Covered
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