Independence Blue Cross

Keystone HMO Silver 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: $500 Family: $1,000 Per Person: $500
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

Office Visit

Primary Doctor	Standard: $40 Copay
Specialist	Standard: $90 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $100 Copay after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $7 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $600 Copay per day
Inpatient Services	Standard: No Charge

Emergency and Urgent Care

Emergency Room

Standard: $950 Copay