Independence Blue Cross

Keystone HMO Silver Basic

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $5,500 Family: $11,000 Per Person: $5,500
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,000 Family: $18,000 Per Person: $9,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $35 Copay
Specialist	Standard: $80 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $3 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 50% Coinsurance after deductible
Inpatient Services	Standard: 50% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $600 Copay