Independence Blue Cross

Keystone HMO Silver Proactive Basic

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: 2500 Family: 5000 Per Person: 2500
Prescription Drug Deductible	Individual: 500 Family: 1000 Per Person: 500
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: $50 Copay
Specialist	Standard: $100 Copay

Prescription Drug Information

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

Inpatient Coverage

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

Emergency and Urgent Care

Emergency Room

Standard: $600 Copay

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