Blue Cross High Deductible Ppo Plan Prescription Cost
Keystone HMO Gold Proactive
Tier 1: $0
Tier 2: $0
Tier 3: $0
Tier 1: $15
Tier 2: $30
Tier 3: $45
Tier 1: $40
Tier 2: $60
Tier 3: $80
Tier 1: $350/day1
Tier 2: $700/day1
Tier 3: $1,100/day1
$20 (all tiers)
Keystone HMO Gold
$0
$35
$65
$750/day1
$15
Personal Choice® PPO Gold
$0
$30
$65
$750/day1
$15
Personal Choice® EPO Gold
$0
$35
$65
$750/day1
$15
Keystone HMO Silver Proactive
Tier 1: $0
Tier 2: $6,000
Tier 3: $6,000
Tier 1: $40
Tier 2: $60 no deductible
Tier 3: $70 no deductible
Tier 1: $80
Tier 2: $120 no deductible
Tier 3: $140 no deductible
Tier 1: $600/day1
Tier 2: Subject to deductible and $900/day1
Tier 3: Subject to deductible and $1,300/day1
$20 no ded ($300 Rx ded for all prescription drugs except generic)
Keystone HMO Silver Proactive Lite
Tier 1: $2,000
Tier 2: $6,500
Tier 3: $6,500
Tier 1: $50 no deductible
Tier 2: $60 no deductible
Tier 3: $70 no deductible
Tier 1: $100 no deductible
Tier 2: $120 no deductible
Tier 3: $140 no deductible
Tier 1: Subject to deductible and $600/day1
Tier 2: Subject to deductible and $900/day1
Tier 3: Subject to deductible and $1,300/day1
$20 no ded ($300 Rx ded for all prescription drugs except generic)
Keystone HMO Silver Proactive Select
Tier 1: $0
Tier 2: $6,000
Tier 3: $6,000
Tier 1: $40
Tier 2: $60 no deductible
Tier 3: $70 no deductible
Tier 1: $80
Tier 2: $120 no deductible
Tier 3: $140 no deductible
Tier 1: $600/day1
Tier 2: Subject to deductible and $900/day1
Tier 3: Subject to deductible and $1,300/day1
$20 no ded ($300 Rx ded for all prescription drugs except generic)
Keystone HMO Silver Proactive Basic
Tier 1: $2,500
Tier 2: $7,000
Tier 3: $7,000
Tier 1: $50 no deductible
Tier 2: $60 no deductible
Tier 3: $70 no deductible
Tier 1: $100 no deductible
Tier 2: $120 no deductible
Tier 3: $140 no deductible
Tier 1: Subject to deductible and $600/day1
Tier 2: Subject to deductible and $900/day1
Tier 3: Subject to deductible and $1,300/day1
$20 no ded ($500 Rx ded for all prescription drugs except generic)
Keystone HMO Silver Proactive Value
Tier 1: $1,500
Tier 2: $6,000
Tier 3: $6,000
Tier 1: $40 no deductible
Tier 2: $60 no deductible
Tier 3: $70 no deductible
Tier 1: $80 no deductible
Tier 2: $120 no deductible
Tier 3: $140 no deductible
Tier 1: Subject to deductible and $600/day1
Tier 2: Subject to deductible and $900/day1
Tier 3: Subject to deductible and $1,300/day1
$20 no ded ($300 Rx ded for all prescription drugs except generic)
Keystone HMO Silver
$3,000
$35 no deductible
$70 no deductible
30% after deductible
$20 no deductible
Keystone HMO Silver Basic
$4,500
$40 no deductible
$80 no deductible
50% after deductible
$20 no deductible (integrated with medical ded)
Personal Choice® PPO Silver
$3,000
$30 no deductible
$70 no deductible
25% after deductible
$20 no deductible (integrated with medical deductible)
Keystone HMO Bronze
$7,400
$75 no deductible
$150 no deductible
Subject to deductible and $700/day1
$25 no deductible (integrated with medical deductible)
Personal Choice® PPO Bronze
$6,000
$50 no deductible
50% after deductible
25% after deductible
$25 no deductible (integrated with medical deductible)
Personal Choice® EPO Bronze Reserve
$7,050
0% after deductible
0% after deductible
0% after deductible
0% after deductible (integrated with medical deductible)
Personal Choice® EPO Bronze Basic
$8,700
Visits 1-3: $20 no deductible
Visits 4+: 0% after deductible
0% after deductible
0% after deductible
$25 no deductible (integrated with medical deductible)
Personal Choice® EPO Catastrophic
$8,700
Visits 1-3: $50 no deductible
Visits 4+: 0% after deductible
0% after deductible
0% after deductible
0% after deductible (integrated with medical deductible)
Source: https://www.ibx.com/find-a-plan/individuals-and-families/ibx-health-plans/health-plans/health-plans-comparison-chart