Anthem BlueCross BlueShield

Anthem HealthKeepers Catastrophic X 8700

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Combined Medical and Drug Deductible	Individual: $8,700.00 Family: $17,400 Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Primary Doctor

CoPay: $40.00
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Primary Care Office Visit has 3 office visits with copay before deductible. Office visits 4 and over are subject to the deductble. Copay is for office visit only, other services provided during the visit are subject to deductible. Copay limit is for Primary Care Office Visits, Other Practitioner Office Visits (Nurse, Physician Assistant), Doctor Visits in the Home, and Online Office Visits combined. Specialists Visits, Mental Health and Substance Use Office Visits apply deductible. 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.

Specialist

CoPay: No Charge after deductible
CoInsurance: Not Applicable
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.

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail.
Generic Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply.

Hospital Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Emergency Room	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Labor and Delivery Hospital Stay	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: This benefit is for the hospital stay.
Pre and Postnatal Office Visit	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Routine Eye Exams For Children

CoPay: $0.00 Copay after deductible
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.

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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