(844) 967-1917
Independence Blue Cross

Keystone HMO Silver Proactive

Plan Overview

Medical Deductable
  • Individual: 0
  • Family: 0
  • Per Person: 0
Prescription Drug Deductible
  • Individual: 300
  • Family: 600
  • Per Person: 300
Medical Out-of-Pocket Maximum
  • Individual: 8700
  • Family: 17400
  • Per Person: 8700
Drug Out-of-Pocket Maximum
  • Individual: Included in Medical
  • Family: Included in Medical
  • Per Person: Included in Medical

Office Visit

Primary Doctor
  • Standard: $40 Copay
Specialist
  • Standard: $80 Copay

Prescription Drug Information

Preferred Brand Drugs
  • Standard: $100 Copay after deductible
Non Preferred Brand Drugs
  • Standard: 50% Coinsurance after deductible
Generic Drugs
  • Standard: $20 Copay
Specialty Drugs
  • Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services
  • Standard: $600 Copay per day
Inpatient Services
  • Standard: No Charge

Emergency and Urgent Care

Emergency Room
  • Standard: $600 Copay
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