Independence Blue Cross

Keystone HMO Silver Proactive Lite

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $2,000 Family: $4,000 Per Person: $2,000
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: $50 Copay
Specialist	Standard: $90 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $90 Copay after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $5 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: $950 Copay