Keystone HMO Silver Proactive Lite
Independence Blue Cross
Plan overview
Medical deductible
Individual: $2000
Family: $4000
Per Person: $2000
Prescription drug deductible
Individual: $225
Family: $450
Per Person: $225
Combined medical and drug out of pocket maximum
Individual: $9200
Family: $18400
Per Person: $9200
Office visit
Primary Doctor
CoPay:
CoInsurance:
Covered:
Benefit Explanation:
Specialist
CoPay:
CoInsurance:
Covered:
Prescription drug information
Preferred brand drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay:
CoInsurance:
Covered:
Inpatient services
CoPay:
CoInsurance:
Covered:
Emergency and urgent care
Emergency room
CoPay:
CoInsurance:
Covered:
Urgent care facility
CoPay:
CoInsurance:
Covered:
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay:
CoInsurance:
Covered:
Pre and Postnatal office visit
CoPay:
CoInsurance:
Covered:
Vision
Routine Eye Exams for Children
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered:
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).