Keystone HMO Bronze

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
$50 copay
Specialist
$100 copay
Preventative Care
No charge

Prescriptions

Generic Drugs
$15 Copay after deductible
Brand Drugs
50% Coinsurance after deductible
Brand Drugs (Non-Preferred)
50% Coinsurance after deductible
Specialty Drugs
50% Coinsurance after deductible

Hospital

Emergency Room
$500 Copay before deductible
Ambulance
50% Coinsurance after deductible
Hospital Stay (Facility)
$700 Copay per Day before deductible
Hospital Stay (Physician)
50% Coinsurance after deductible
Outpatient Procedure (Facility)
$600 Copay before deductible
Outpatient Procedure (Physician)
50% Coinsurance after deductible

Pregnancy

Delivery
$700 Copay before deductible
Well Baby Visits
No charge

Mental Health

Outpatient Services
$100 copay
Psychiatric Hospital Stay
$700 Copay per Day before deductible

Diagnostics / Labs / Imaging

X-Rays
$100 copay
CT Scans, Pet Scans and MRIs
$250 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.