Independence Blue Cross

Keystone HMO Bronze

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: 7400 Family: 14800 Per Person: 7400
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
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: $75 Copay
Specialist	Standard: $150 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $25 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $700 Copay per day with deductible
Inpatient Services	Standard: 50% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $500 Copay with deductible

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