Anthem HealthKeepers Silver X 5800 Standard
Anthem HealthKeepers Silver X 5800 Standard is a Silver HMO plan by HealthKeepers, Inc..
IMPORTANT: You are viewing the 2023 version of Anthem HealthKeepers Silver X 5800 Standard 88380VA0720046. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Anthem HealthKeepers Silver X 5800 Standard is offered in the following counties.
Plan Overview
Insurer: | HealthKeepers, Inc. |
Network Type: | HMO |
Metal Type: | Silver |
HSA Eligible?: | No |
Plan ID: | 88380VA0720046 |
Cost-Sharing Overview
Anthem HealthKeepers Silver X 5800 Standard offers the following cost-sharing.
Cost-sharing for Anthem HealthKeepers Silver X 5800 Standard includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Pocket Maximum: | $8,900.00 | $8900 per person | $17800 per group |
Deductible: | $5,800.00 | $5800 per person | $11600 per group |
Coinsurance: | 40.00% |
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Anthem HealthKeepers Silver X 5800 Standard will be shown below if applicable.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
Out-of-Network Deductible: | Not Applicable | per person not applicable | per group not applicable |
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
Deductible: | $5,800.00 |
Copayment: | $10.00 |
Coinsurance: | $2,700.00 |
Limit: | $60.00 |
Deductible: | $100.00 |
Copayment: | $1,600.00 |
Coinsurance: | $0.00 |
Limit: | $20.00 |
Deductible: | $2,100.00 |
Copayment: | $400.00 |
Coinsurance: | $0.00 |
Limit: | $0.00 |
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.
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 Silver X 5800 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 Silver X 5800 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 Silver X 5800 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 | $40.00 | 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 | $80.00 | 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 | $40.00 | 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 | 40.00% Coinsurance after deductible | 100.00% | |
Outpatient Surgery Physician/Surgical Services Covered | 40.00% Coinsurance after deductible | 100.00% | |
Hospice Services Covered | 40.00% 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 | 40.00% 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 | $60.00 | $60.00 | |
Home Health Care Services Covered | 40.00% 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 | 40.00% Coinsurance after deductible | 40.00% Coinsurance after deductible | |
Emergency Transportation/Ambulance Covered | 40.00% Coinsurance after deductible | 40.00% 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 | 40.00% Coinsurance after deductible | 100.00% | |
Inpatient Physician and Surgical Services Covered | 40.00% Coinsurance after deductible | 100.00% | |
Bariatric Surgery Not Covered | |||
Cosmetic Surgery Not Covered | |||
Skilled Nursing Facility Covered | 40.00% Coinsurance after deductible | 100.00% | 100 Days per Stay Limited to 100 days per stay. |
Prenatal and Postnatal Care Covered | 40.00% Coinsurance after deductible | 100.00% | |
Delivery and All Inpatient Services for Maternity Care Covered | 40.00% Coinsurance after deductible | 100.00% | This benefit is for the hospital stay. |
Mental/Behavioral Health Outpatient Services Covered | $40.00 | 100.00% | |
Mental/Behavioral Health Inpatient Services Covered | 40.00% Coinsurance after deductible | 100.00% | |
Substance Abuse Disorder Outpatient Services Covered | $40.00 | 100.00% | |
Substance Abuse Disorder Inpatient Services Covered | 40.00% Coinsurance after deductible | 100.00% | |
Generic Drugs Covered | $20.00 | 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 | $40.00 | 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 | $80.00 Copay after deductible | 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 | $350.00 Copay after deductible | 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 | $40.00 | 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 | $40.00 | 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 | 40.00% 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 | 40.00% 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 | 40.00% 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 | $40.00 | 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 | $40.00 | 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 | 40.00% Coinsurance after deductible | 100.00% | |
X-rays and Diagnostic Imaging Covered | 40.00% 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 | 40.00% 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 | $80.00 | 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 | 40.00% Coinsurance after deductible | 100.00% | |
Allergy Testing Covered | 40.00% Coinsurance after deductible | 100.00% | |
Chemotherapy Covered | 40.00% Coinsurance after deductible | 100.00% | |
Radiation Covered | 40.00% Coinsurance after deductible | 100.00% | |
Diabetes Education Covered | $80.00 | 100.00% | Cost-Share(s) determined based on type of service and place of service rendered. |
Prosthetic Devices Covered | 40.00% 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 | 40.00% Coinsurance after deductible | 100.00% | |
Treatment for Temporomandibular Joint Disorders Covered | 40.00% Coinsurance after deductible | 100.00% | |
Nutritional Counseling Covered | $40.00 | 100.00% | |
Reconstructive Surgery Covered | 40.00% Coinsurance after deductible | 100.00% | |
Gender Affirming Care |
Free Preventive Services
There is no copayment or coinsurance for any of the following Anthem HealthKeepers Silver X 5800 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.
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Anthem HealthKeepers Silver X 5800 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 |
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