Anthem HealthKeepers Bronze DED 5500
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Customer Reviews: Not Yet Rated
Plan Summary | |
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Plan Type | HMO |
Office Visit for Primary Doctor
|
$30 Copay |
Office Visit for Specialist | 35% Coinsurance after deductible |
Office Visit for Other Practitioner (Nurse, Physician Assistant) | $30 Copay |
Annual Deductible | Individual: $5,500 |
Separate Prescription Drugs Deductible | Medical Plan Deductible Applies |
Coinsurance | 35% |
Retail Prescription Drugs | Generic Drugs: 35% Coinsurance after deductible; Preferred Brand Drugs: 40% Coinsurance after deductible; Non-Preferred Brand Drugs: 45% Coinsurance after deductible; Specialty Drugs: 50% Coinsurance after deductible; |
Annual Out-of-Pocket Limit | Individual: $9,200 Includes deductible |
Lifetime Maximum | Unlimited |
Health Savings Account (HSA) Eligible | No |
Out-of-Network Coverage | No |
Out-of-Country Coverage | Emergency Care Only. |
Office Visit | |
Primary Care Physician Required | Yes |
Specialist Referrals Required | No |
Preventive Care Coverage | |
Periodic Health Exam | No Charge |
Periodic OB-GYN Exam | No Charge |
Well Baby Care | No Charge |
Emergency and Urgent Care | |
Emergency Room | 50% Coinsurance after deductible |
Emergency Ambulance Services | 35% Coinsurance after deductible |
Urgent Care Facility | $60 Copay |
Prescription Drug Coverage | |
Retail Prescription Drugs | Generic Drugs: 35% Coinsurance after deductible; Preferred Brand Drugs: 40% Coinsurance after deductible; Non-Preferred Brand Drugs: 45% Coinsurance after deductible; Specialty Drugs: 50% Coinsurance after deductible; |
Separate Prescription Drugs Deductible | Medical Plan Deductible Applies |
Mail Order Prescription Drugs | N/A |
Mail Order Supply | N/A |
Outpatient Coverage | |
Outpatient Surgery | Outpatient Surgery Physician/Surgical Services: 35% Coinsurance after deductible Outpatient Facility Fee: 35% Coinsurance after deductible |
Outpatient Lab/X-Ray | Outpatient Lab: 35% Coinsurance after deductible X-rays: 35% Coinsurance after deductible |
Imaging (CT and PET scans, MRIs) | 50% Coinsurance after deductible |
Outpatient Mental Health | 35% Coinsurance after deductible |
Outpatient Substance Abuse | 35% Coinsurance after deductible |
Outpatient Rehabilitation Services (PT, OT, ST) | 35% Coinsurance after deductible, limited to 30 Visit(s) per Benefit Period |
Inpatient Coverage | |
Hospitalization | Inpatient Hospital Services: 35% Coinsurance after deductible Inpatient Physician and Surgical Services: 35% Coinsurance after deductible |
Skilled Nursing Facility | 35% Coinsurance after deductible, limited to 100 Days per Stay |
Inpatient Mental Health | 35% Coinsurance after deductible |
Inpatient Substance Abuse | 35% Coinsurance after deductible |
Home Healthcare | 35% Coinsurance after deductible, limited to 100 Visit(s) per Benefit Period |
Maternity Coverage | |
Pre & Postnatal Office Visit | 35% Coinsurance after deductible |
Labor & Delivery Hospital Stay | 35% Coinsurance after deductible |
Pediatric Services | |
Dental Checkup for Children | No Charge after deductible, limited to 2 Visit(s) per Year |
Vision Screening for Children | No Charge, limited to 1 Visit(s) per Benefit Period |
Eye Glasses for Children | No Charge, limited to 1 Item(s) per Year |
Major Dental Coverage (Pediatric) | 50% Coinsurance after deductible |
Additional Coverage | |
Chiropractic Coverage | 35% Coinsurance after deductible, limited to 30 Visit(s) per Benefit Period |
Durable Medical Equipment | 35% Coinsurance after deductible |
Hospice | 35% Coinsurance after deductible |
Major Dental Coverage (Adult) | Not Covered |
Vision Coverage (Adult) | Not Covered |
Out-of-Network Coverage | |
Out-of-Network Authorization Required | N/A |
Out-of-Network Annual Deductible | N/A |
Out-of-Network Annual Coinsurance | N/A |
Out-of-Network Annual Out-of-Pocket Limit | N/A |
Additional Information | |
A.M. Best Rating | A as of 12/19/2023 |
Electronic Signature for Application Available | Yes |
Details and documents about this plan | |
View Plan Brochure Exclusions and Limitations |
Important notices and disclaimers
- The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
- The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
- The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
- Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
- The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
- The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.
Carrier specific notices, disclaimers and fees
- Anthem Blue Cross and Blue Shield - This is not your policy and is intended as a brief summary of services. If there is any difference between this page and the policy, the provisions of the policy shall control. To understand the terms of the individual policy you are considering, please read the Policy Terms, including Exclusions and Limitations. This page refers to Policy Form #s 901119-CP.1 et al., 901151-CP et al., Schedule of Benefits Form #s AVA1513, AVA1515, PVA1721, PVA1723, 901152 or PVA2326, and Application Form #s AVA1528, AVA1529, AVA1531,AVA1533, AVA1534, AVA1536, AVA1313 or AVA1537, AVA1359 AVA1459, or AVA1572 and optional coverage form #s AVA1347, AVA1392, AVA1393, AVA1517, 901167, and 901165, AVA1563 or AVA1564.