Independence Blue Cross Keystone Hmo Silver Proactive Plan Id 33871pa0040006
Keystone HMO Silver Proactive
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| Plan id | 33871PA0040006-04 |
| CSR Variation Type | 73% AV Level Silver Plan |
Insurance Company  | Independence Blue Cross |
| Plan Type | HMO |
| Plan Metal Level | Silver |
| Link to Plan's Doctor Directory | View Plan's Doctor Directory |
| List of Hospitals in Plan's Network | Show Hospitals |
| Summary of Benefits and Coverage | View Summary of Benefits and Coverage |
| Estimated Monthly Premium Savings (APTC) | |
| Monthly Premium Cost after Subtracting the Estimated Subsidy (Subsidies are not available for Catastrophic Plans) | |
| Cost in a Good Year: Estimated Yearly Cost to You if Your Health Care Usage is Low (for Very Healthy Consumers "Low" is Defined as Only Preventive Care) | |
| Your Chances of Having a Good Year--a Year with No More Than Low-Usage | |
| Cost in an Average Year: Average for People Like You | |
| Cost in a Bad Year: Estimate for People Like You in a High-Health Care Usage Year | |
| Your Chances of Having a Bad Year--a Year with Very High Usage | |
| Actual Maximum Out-of-Pocket (includes premiums) | |
Benefits and Coverage (assuming you use preferred providers)  (Note: For a more detailed and accurate explanation of the benefits offered by this plan please refer to the Summary of Benefits and Coverage [SBC]. The benefits are described in more detail in the SBC and it will include additional information about those benefits. Some nuances about the benefits like visit limits and other details are not listed below. You should refer to the SBC for those details about the plan. Click on the "View Summary of Benefits and Coverage" link above to view the SBC.) | |
|---|---|
| In-Network Deductible (Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.) | $0 |
| Extra Deductible for Drugs | $0 |
| Doctor Visits | |
| Doctor Visit - Preventive Care | No Charge |
| Doctor Visit - Primary Care | Copay: $40.00 |
| Doctor Visit - Specialist | Copay: $80.00 |
| Doctor Visit - Well Baby Visits and Care | Copay: $80.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | Copay: $40.00 |
| Hospital | |
| Inpatient Hospital Facility | Copay: $500.00 Copay per Day |
| Inpatient Hospital Physician/Surgeon | No Charge |
| Outpatient Hospital Facility | Copay: $250.00 |
| Outpatient Hospital Physician/Surgeon | No Charge |
| Inpatient Maternity Services | Copay: $500.00 |
| Emergency | |
| Emergency Room Services | Copay: $550.00 |
| Emergency Medical Transportation | Copay: $200.00 |
| Urgent Care Centers or Facilities | Copay: $100.00 |
| Drugs | |
| Plan's Drug Formulary | View Plan's Drug Formulary |
| Generic Drug on Formulary in a Local Pharmacy | Copay: $20.00 |
| Preferred Brand Drug on Formulary in a Local Pharmacy | Coinsurance: 50.00% |
| Non-Preferred Brand Drug on Formulary in a Local Pharmacy | Coinsurance: 50.00% |
| Specialty Drug on Formulary in a Local Pharmacy | Coinsurance: 50.00% |
| Tests & Imaging | |
| Diagnostic Tests (Blood work) | No Charge |
| X-Rays | Copay: $120.00 |
| Imaging (CT/PET Scans, MRI, etc) | Copay: $250.00 |
| Mental/Behavioral Health | |
| Mental/Behavioral Health Inpatient Services | Copay: $500.00 Copay per Day |
| Mental/Behavioral Health Outpatient Services | Copay: $80.00 |
| Substance Use Disorder Inpatient | Copay: $500.00 Copay per Day |
| Substance Use Disorder Outpatient | Copay: $80.00 |
| Vision/Hearing Aids | |
| Routine Eye Exam for Child | No Charge |
| Eye Glasses for Child | No Charge |
| Routine Eye Exam - Adult | Not Covered |
| Hearing Aids | Not Covered |
| Child Dental Coverage | |
| Dental Check-Up for Children | No Charge |
| Basic Dental Care – Child | Coinsurance: 50.00% Coinsurance after deductible |
| Major Dental Care – Child | Coinsurance: 50.00% Coinsurance after deductible |
| Orthodontia – Child | Coinsurance: 50.00% Coinsurance after deductible |
| Adult Dental Coverage | |
| Basic Dental Care – Adult | Not Covered |
| Major Dental Care – Adult | Not Covered |
| Orthodontia – Adult | Not Covered |
| Accidental Dental | Coinsurance: 20.00% |
| Home and Nursing Care | |
| Home Health Care Services | No Charge |
| Skilled Nursing Care - Facility | Copay: $250.00 Copay per Day |
| Rehabilitative and habilitative services | |
| Habilitation Services | Copay: $80.00 |
| Outpatient Rehabilitation Services | Copay: $80.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | Copay: $80.00 |
| Rehabilitative Speech Therapy | Copay: $80.00 |
| Other Services | |
| Is HSA Eligible? | No |
| Allergy Testing | Copay: $120.00 |
| Chemotherapy | No Charge |
| Chiropractic | Copay: $50.00 |
| Diabetes Education | No Charge |
| Dialysis | Copay: $30.00 |
| Durable Medical Equipment | Coinsurance: 50.00% |
| Hospice Service | No Charge |
| Infusion Therapy | No Charge |
| Nutritional Counseling | No Charge |
| Prosthetic Devices | Coinsurance: 50.00% |
| Radiation | No Charge |
| Reconstructive Surgery | Copay: $500.00 |
| Routine Foot Care | Not Covered |
| Treatment for Temporomandibular Joint Disorders | Not Covered |
| Transplant | Copay: $500.00 |
| Weight Loss Programs | Not Covered |
| Wellness Programs | |
| Asthma Program | Available |
| Heart Disease Program | Available |
| Depression Program | Not Available |
| Diabetes Program | Available |
| High Blood Pressure & Cholesterol Program | Available |
| Low Back Pain Program | Available |
| Pain Management Program | Available |
| Pregnancy Program | Available |
| Weight Loss Programs | Not Available |
| Out-of-Network - See Summary of Benefits and Coverage | View Summary of Benefits and Coverage |
Source: https://pa.checkbookhealth.org/hie/PA/2019/health-plans/33871PA0040006-04-Keystone-HMO-Silver-Proactive-73-percent-AV-Level-Silver-Plan
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