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Frequently Asked Questions
Independence Blue Cross - Personal Choice EPO Bronze Basic
Benefits Resources
Provider Directory
Summary of Benefits and Coverage
Download Plan Brochure
Drug List
Summary
Plan Type
EPO
HSA-compatible
No
Overall Quality Rating
Not Available
Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
First 3 visits at $20 Copay, then No Charge after deductible
100% Coinsurance
Specialist Visit
No Charge after deductible
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$20 Copay,
No Charge after deductible
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
No Charge after deductible
100% Coinsurance
X-rays and Diagnostic Imaging
No Charge after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
No Charge after deductible
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
$25 Copay
70% Coinsurance
Preferred Brand Drugs
No Charge after deductible
70% Coinsurance after deductible
Non-Preferred Brand Drugs
No Charge after deductible
70% Coinsurance after deductible
Specialty drugs
No Charge after deductible
100% Coinsurance
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
No Charge after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
No Charge after deductible
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
No Charge after deductible
No Charge after deductible
Emergency Transportation/Ambulance
No Charge after deductible
No Charge after deductible
Urgent Care
No Charge after deductible
100% Coinsurance
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
No Charge after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
No Charge after deductible
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
No Charge after deductible
100% Coinsurance
Mental/Behavioral Health Inpatient Services
No Charge after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
No Charge after deductible
100% Coinsurance
Substance Abuse Disorder Inpatient Services
No Charge after deductible
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
No Charge after deductible
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
No Charge after deductible
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
No Charge after deductible
100% Coinsurance
Outpatient Rehabilitation Services
No Charge after deductible
100% Coinsurance
Habilitation Services
No Charge after deductible
100% Coinsurance
Skilled Nursing Facility
No Charge after deductible
100% Coinsurance
Durable Medical Equipment
No Charge after deductible
100% Coinsurance
Hospice Services
No Charge after deductible
100% Coinsurance
Chiropractic Care
No Charge after deductible
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
No Charge after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
No Charge after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
No Charge after deductible
100% Coinsurance
Diabetes Education
No Charge after deductible
100% Coinsurance
Nutritional Counseling
No Charge
100% Coinsurance
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
No Charge after deductible
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
No Charge after deductible
100% Coinsurance
Dental Check Up (Child)
No Charge
100% Coinsurance
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
No Charge after deductible
100% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
No Charge after deductible
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered
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