Independence Blue Cross

Keystone HMO Gold Proactive

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

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: 8550 Family: 17100 Per Person: 8550
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

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

Prescription Drug Information

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

Inpatient Coverage

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

Emergency and Urgent Care

Emergency Room

Standard: $400 Copay

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