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Anthem HealthKeepers Gold X 2000 Standard

88380VA0720047
Gold
HMO

Anthem HealthKeepers Gold X 2000 Standard is a Gold HMO plan by HealthKeepers, Inc..

IMPORTANT: You are viewing the 2023 version of Anthem HealthKeepers Gold X 2000 Standard 88380VA0720047. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Anthem HealthKeepers Gold X 2000 Standard is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Anthem HealthKeepers Gold X 2000 Standard 88380VA0720047.
Insurer: HealthKeepers, Inc.
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 88380VA0720047

Cost-Sharing Overview

Anthem HealthKeepers Gold X 2000 Standard offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Anthem HealthKeepers Gold X 2000 Standard?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Anthem HealthKeepers Gold X 2000 Standard offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Anthem HealthKeepers Gold X 2000 Standard covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description: Urgent/Emergency Coverage Only
Out of Service Area Coverage: No
Out of Service Area Coverage Description: TRAD/PAR network
National Network: No

Additional Benefits and Cost-Sharing

Anthem HealthKeepers Gold X 2000 Standard includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 100.00% Copay is for Primary Care office visits, Mental Health and Substance Use Office Visits, and Physical, Occupational and Speech Therapies. Other services provided during the visit are subject to additional cost shares. 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 mobile application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered.
Specialist Visit
Covered
$60.00 100.00% Copays do apply to Specialists Visits. Other services provided during the visit are subject to additional cost shares. 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 mobile application, website, or HealthKeepers enabled device.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00% 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 mobile application, website, or HealthKeepers enabled device.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
25.00% Coinsurance after deductible 100.00%16 Hours per Benefit Period Private-Duty nursing in a home setting only. Limited to 16 hours per benefit period.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 $45.00
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%100 Visit(s) per Benefit Period The Home Care visit limit will apply instead of the Therapy Services limits for physical, occupational, speech therapy, or cardiac rehabilitation for therapy in the home. Visit limit does not apply to home infusion therapy or home dialysis. Limited to 100 visits per benefit period.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible Benefits for Non-Emergency ambulance services when services have been pre-authorized by Anthem will be limited to $50,000 per occurrence if a Non-Network Provider is used. Includes medically necessary transportation to the nearest appropriate hospital for a medical emergency, or between hospitals or other approved facilities. Includes ground, water, fixed wing and rotary air transportation. Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility. Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%100 Days per Stay Limited to 100 days per stay.
Prenatal and Postnatal Care
Covered
25.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00% This benefit is for the hospital stay.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$15.00 100.00% 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. 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.
Preferred Brand Drugs
Covered
$30.00 100.00% 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. 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
Covered
$60.00 100.00% 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. 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
Covered
$250.00 100.00% 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. 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.
Outpatient Rehabilitation Services
Covered
$30.00 100.00%30 Visit(s) per Benefit Period Rehabilitation Speech therapy limited to 30 visits per year. Rehabilitative Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Rehabilitative service limits are not combined with Habilitation service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Habilitation Services
Covered
$30.00 100.00%30 Visit(s) per Benefit Period Habilitation Speech therapy limited to 30 visits per year. Habilitative Physical therapy and Occupational therapy have a combined limit of 30 visits per benefit period. Habilitative service limits are not combined with Rehabilitation service limits. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.
Chiropractic Care
Covered
25.00% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period Rehabilitative Chiropractic care / spinal manipulation is limited to 30 visits per benefit period. Habilitative Chiropractic care / spinal manipulation is limited to 30 visits per year. Habilitation service limits are not combined with Rehabilitative service limits.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00% Coverage for ongoing rental of equipment may be limited to the cost of purchasing the equipment.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00% You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Benefit Period 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.
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year Includes a choice of eyeglasses lenses or contact lenses within a benefit period. Covered eyeglasses lenses include standard plastic lenses in: Single vision, Bifocal, Trifocal, and Standard Progressive. Members choose from a limited frame selection. Coverage for contact lenses includes elective or non-elective contact lenses. Non-elective contact lenses are covered only for certain medical conditions. Limited to 1 item per year.
Dental Check-Up for Children
Covered
No Charge after deductible 100.00%2 Visit(s) per Year Limited to 2 visits per year.
Rehabilitative Speech Therapy
Covered
$30.00 100.00%30 Visit(s) per Benefit Period Rehabilitation Speech therapy limited to 30 visits per benefit period. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%30 Visit(s) per Benefit Period Rehabilitation Physical therapy and Occupational therapy limited to 30 visits per benefit period combined. The limits for Physical, Occupational, and Speech therapy will not apply if you get that care as part of the Hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. Rehabilitative service limits are not combined with Habilitation service limits.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
40.00% Coinsurance after deductible 100.00%
Orthodontia – Child
Covered
50.00% Coinsurance after deductible 100.00% Orthodontic Fixed Appliance Therapy, which is treatment that uses an appliance that is cemented or bonded to the teeth, is covered only once per lifetime for Dentally Necessary Coverage only.
Major Dental Care – Child
Covered
50.00% Coinsurance after deductible 100.00%
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 100.00% Unrelated Donor Search limited to a maximum of the 10 best matched donors, identified by an authorized registry. Medically Necessary charges for the procurement of an organ from a live donor are covered up to the maximum allowed amount, including complications from the donor procedure for up to six weeks from the date of procurement.
Accidental Dental
Covered
$60.00 100.00% Treatment must begin within 12 months of the injury, or as soon after that as possible, to be covered. Cost-Share(s) determined based on type of service and place of service rendered.
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
25.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$60.00 100.00% Cost-Share(s) determined based on type of service and place of service rendered.
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00% The coinsurance for prosthetics for limb replacement can be no greater than 30%. Per the mandate “Limb” means an arm, a hand, a leg, a foot, or any portion of an arm, a hand, a leg, or a foot. All other prosthetic services are covered under the plan’s base coinsurance (Coinsurance formula: If plan coinsurance is greater than 30% then coinsurance for Prosthetics for Limb Replacement is 30%. If plan coinsurance is equal to a less than 30% then consurance for Prosthetics for Limb Replacement, should be the plan coinsurance).
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$30.00 100.00%
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00%
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following Anthem HealthKeepers Gold X 2000 Standard preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Anthem HealthKeepers Gold X 2000 Standard including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Anthem HealthKeepers Gold X 2000 Standard?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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