Anthem BlueCross BlueShield

Anthem HealthKeepers Catastrophic X DED 9200

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Plan Overview

Combined Medical and Drug Deductible	Individual: $9,200 Family: $18400 Per Person: $9200
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor

CoPay: $40.00
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Primary Care Office Visit has 3 copays only; visit 4+, no charge after deductible. Copay is for office visit only, other services provided during the visit are subject to additional cost shares. Copay limit is for Primary Care Office Visits and Other Practitioner Office Visits (Nurse, Physician Assistant) 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 designated network of virtual doctors. These designated virtual doctors can be accessed via our mobile application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered.

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 designated network of virtual doctors. These designated virtual doctors can be accessed via our mobile application, website, or HealthKeepers enabled device.

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.
Generic Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply retail. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 30 day supply. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

Inpatient Coverage

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 and Urgent Care

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

Maternity

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

Vision

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.

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
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Anthem HealthKeepers Catastrophic X DED 9200

Plan Overview

Office Visit

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Maternity

Vision

Major Dental Care

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