Independence Blue Cross

Keystone HMO Gold Proactive

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Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Primary Doctor	Standard: $15 Copay
Specialist	Standard: $40 Copay

Hospital Services	Standard: $350 Copay per day
Inpatient Services	Standard: No Charge

Emergency Room