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. Cost if you use an Cost if you use a Covered Medical Benefits In-Network Non-Network Provider Provider Overall Deductible $1,000 person / $2,000 person / See notes section to understand how your deductible works. Your plan may also have $2,000 family $4,000 family a separate Prescription Drug Deductible. See Prescription Drug Coverage section. Out-of-Pocket Limit $4,500 person / $9,000 person / When you meet your out-of-pocket limit, you will no longer have to pay cost-shares $9,000 family $18,000 family during the remainder of your benefit period. See notes section for additional information regarding your out of pocket maximum. Preventive care/screening/immunization No charge 30% coinsurance In-network preventive care is not subject to deductible, if your plan has a after deductible is deductible. 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 30% coinsurance after deductible is after deductible is met met
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
Franklin-City-Public-Schools-2018-SPD-Anthem-HealthKeepers-POS-OA-30-1000-20-4500.docx