HealthKeepers, Inc. Your Contract Code: 3992 Your Plan: Anthem HealthKeepers POS OA 30 1000/20%/4500 Your Network: HealthKeepers This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This policy has exclusions and limitations to benefits and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your insurance agent or contact us. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail. This benefit summary is not to be distributed without also providing access to the applicable Anthem HealthKeepers enrollment brochure. Covered Medical Benefits Cost if you use an In-Network Provider Cost if you use a Non-Network Provider Overall Deductible See notes section to understand how your deductible works. Your plan may also have a separate Prescription Drug Deductible. See Prescription Drug Coverage section. $1,000 person / $2,000 family $2,000 person / $4,000 family Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. See notes section for additional information regarding your out of pocket maximum. $4,500 person / $9,000 family $9,000 person / $18,000 family Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible. No charge 30% coinsurance after deductible is met Doctor Home and Office Services Primary care visit to treat an injury or illness $30 copay per visit 30% coinsurance after deductible is met Specialist care visit $50 copay per visit 30% coinsurance after deductible is met Prenatal and Post-natal Care 20% coinsurance after deductible is met 30% coinsurance after deductible is met
Other practitioner visits: Retail health clinic $30 copay per visit 30% coinsurance after deductible is met On-line Medical Visit Live Health Online is the preferred telehealth solutions () $20 copay per visit 30% coinsurance after deductible is met Chiropractic services Coverage for In-Network Provider and Non-Network Provider combined is limited to 30 visits for Rehabilitation and Habilitative per benefit period. $30 copay per visit 30% coinsurance after deductible is met Other services in an office: Allergy testing $30 copay per visit 30% coinsurance after deductible is met Chemo/radiation therapy 20% coinsurance after deductible is met 30% coinsurance after deductible is met Dialysis/Hemodialysis 20% coinsurance after deductible is met 30% coinsurance after deductible is met Prescription drugs For the drugs itself dispensed in the office thru infusion/injection] 20% coinsurance after deductible is met 30% coinsurance after deductible is met Diagnostic Services Lab: Office 20% coinsurance after deductible is met 30% coinsurance after deductible is met Preferred Reference Lab Covered in Full 30% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 30% coinsurance after deductible is met
X-ray: Office 20% coinsurance after deductible is met 30% coinsurance after deductible is met Freestanding Radiology Center 20% coinsurance after deductible is met 30% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 30% coinsurance after deductible is met Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office 20% coinsurance after deductible is met 30% coinsurance after deductible is met Freestanding Radiology Center 20% coinsurance after deductible is met 30% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 30% coinsurance after deductible is met Emergency and Urgent Care Emergency room facility services Copay waived if admitted 20% coinsurance after deductible is met Covered as Emergency room doctor and other services 20% coinsurance after deductible is met Covered as Ambulance Transportation 20% coinsurance after deductible is met Covered as Urgent Care Center Office Visit $50 copay per visit 30% coinsurance after deductible is met