IBX Keystone HMO $30 Copay – Pennsylvania Health Insurance Plan
A detailed comparison of the IBX Keystone HMO $30 Copay health insurance plan as offered in Pennsylvania is listed below for both Network and Non-Network coverage. This is a review of the coverage for this specific IBX plan. However, GoHealthInsurance offers a large variety of health insurance options to fit your needs. If you wish, get a new IBX health insurance quote for Pennsylvania now or view all of our IBX health insurance quotes.
| Network | Non-Network | |
|---|---|---|
| Copay | $30 | $30 |
| OfficeVisit | Primary care office visit: $30; Specialist office visit: $50 | Primary care office visit: $30; Specialist office visit: $50 |
| Deductible false | None | None |
| Coinsurance | None | None |
| Coinsurance Limit | None | None |
| Out-of-Pocket Maximum | N/A | N/A |
| Lifetime Maximum | Unlimited | Unlimited |
| Prescription Drugs | Prescription deductible, individual family: $400/$1200; Generic formulary copay: $10, after prescription deductible; Brand formulary: 30 % coinsurance, $250 maximum copay , after prescription deductible; Non-formulary: 40% coinsurance, $250 maximum cop | Prescription deductible, individual family: $400/$1200; Generic formulary copay: $10, after prescription deductible; Brand formulary: 30 % coinsurance, $250 maximum copay , after prescription deductible; Non-formulary: 40% coinsurance, $250 maximum cop |
| Emergency Room | Emergency room (not waived if admitted): $200; Ambulance: $0 | Emergency room (not waived if admitted): $200; Ambulance: $0 |
| Adult Preventative Care | Routine gynecological exam/Pap test : $0 (no referral required, 1 per year) ; Mammogram (no referral required) : $0; Nutrition counseling (6 visits per year) : $0 | Routine gynecological exam/Pap test : $0 (no referral required, 1 per year) ; Mammogram (no referral required) : $0; Nutrition counseling (6 visits per year) : $0 |
| Child Preventative Care | Pediatric immunizations: $0 | Pediatric immunizations: $0 |
| Lab / X-Ray | Outpatient lab/pathology: $0; Routine radiology/diagnostic: $50; MRI/MRA, CT/CTA scan,PET scan: $100 | Outpatient lab/pathology: $0; Routine radiology/diagnostic: $50; MRI/MRA, CT/CTA scan,PET scan: $100 |
| Maternity | $500 Amount shown reflects the copayment per day. There is a maximum of five copayments per admission. | $500 Amount shown reflects the copayment per day. There is a maximum of five copayments per admission. |
| Physical Therapy | Physical/occupational therapy (30 visits per year): $50(combined in and out-of-network); Spinal manipulations (20 visits per year): $50(combined in and out-of-network) | Physical/occupational therapy (30 visits per year): $50(combined in and out-of-network); Spinal manipulations (20 visits per year): $50(combined in and out-of-network) |
| Home Health Care | N/A | N/A |
| Mental Health | Not covered | Not covered |
| Hospital Care | Inpatient hospital services: $500 per day, maximum of 5 copayments per admission; Outpatient surgery: $500 | Inpatient hospital services: $500 per day, maximum of 5 copayments per admission; Outpatient surgery: $500 |
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