Independence Blue Cross - Keystone HMO Silver Proactive
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$5 Copay
100% Coinsurance
Specialist Visit
$15 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$5 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
No Charge
100% Coinsurance
X-rays and Diagnostic Imaging
$10 Copay
100% Coinsurance
Imaging (CT/PET scans, MRIs)
$20 Copay
100% Coinsurance
Generic Drugs
$4 Copay
70% Coinsurance
Preferred Brand Drugs
$15 Copay
70% Coinsurance
Non-Preferred Brand Drugs
5% Coinsurance
70% Coinsurance
Specialty drugs
30% Coinsurance
100% Coinsurance
Outpatient Facility Fee
$50 Copay
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
No Charge
100% Coinsurance
Emergency Room Services
$50 Copay
$50 Copay
Emergency Transportation/Ambulance
$25 Copay
$25 Copay
Urgent Care
$15 Copay
100% Coinsurance
Inpatient Hospital Services
$50 Copay per day
100% Coinsurance
Inpatient Physician and Surgical Services
No Charge
100% Coinsurance
Mental/Behavioral Health Outpatient Services
$15 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$50 Copay per day
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$15 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$50 Copay per day
100% Coinsurance
Prenatal and postnatal care
$15 Copay
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$50 Copay
100% Coinsurance
Home Healthcare Services
No Charge
100% Coinsurance
Outpatient Rehabilitation Services
$15 Copay
100% Coinsurance
Habilitation Services
$15 Copay
100% Coinsurance
Skilled Nursing Facility
$25 Copay per day
100% Coinsurance
Durable Medical Equipment
20% Coinsurance
100% Coinsurance
Hospice Services
No Charge
100% Coinsurance
Chiropractic Care
$50 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
$15 Copay
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
$15 Copay
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$10 Copay
100% Coinsurance
Diabetes Education
No Charge
100% Coinsurance
Nutritional Counseling
No Charge
100% Coinsurance
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
20% Coinsurance
100% Coinsurance
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
50% Coinsurance after deductible
100% Coinsurance
Dental Check Up (Child)
No Charge
100% Coinsurance
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
50% Coinsurance after deductible
100% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
50% Coinsurance after deductible
100% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered