Keystone HMO Platinum

Independence Blue Cross

Plan Network

To see how this plan's network compares to others in your area, we will need your zip code.

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Plan Coverage
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Doctor Visits

Primary Care
First 4 visits free
$15 copay
Specialist
$30 copay
Preventative Care
No charge

Prescriptions

Generic Drugs
$5 copay
Brand Drugs
$30 copay
Brand Drugs (Non-Preferred)
$50 copay
Specialty Drugs
50% coinsurance

Hospital

Emergency Room
$250 copay
Ambulance
$50 copay
Hospital Stay (Facility)
$400 Copay per Day
Hospital Stay (Physician)
No charge
Outpatient Procedure (Facility)
$100 copay
Outpatient Procedure (Physician)
No charge

Pregnancy

Delivery
$400 copay
Well Baby Visits
No charge

Mental Health

Outpatient Services
$30 copay
Psychiatric Hospital Stay
$400 Copay per Day

Diagnostics / Labs / Imaging

X-Rays
$30 copay
CT Scans, Pet Scans and MRIs
$60 copay
Lab Tests
No charge

Free Preventative Care

If you use an in-network doctor, this plan will provide all preventative care services at no cost.

List of covered services

Out of Network

If you use out-of-network providers under this plan, you may have to pay more or even full price. Out of Network care doesn't count towards your deductible and maximum out-of-pocket.