Anthem BlueCross BlueShield

Anthem HealthKeepers Bronze X 5500

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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

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.

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.

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

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

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.

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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