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If you would like to request a quote, call 1-888-249-2118 .
FAQ
View our most frequently asked questions.
PPO 30 Copay
Your current plan
| PPO 30 Copay (you pay) | ||
|---|---|---|
| Benefits summary |  PPO 30 Copay |
|
| Location | In-network (you pay) | Out-of-network (you pay) |
| Office visit | $30 | 50%, after deductible |
| Specialist visit | $50 | 50%, after deductible |
| Hospitalization | 20%; unlimited days | 50%, after deductible/ 70 days |
HMO cost-saving options
| HMO 1500 Deductible (you pay) |
HMO 2500 Deductible (you pay) |
HMO 5000 Deductible (you pay) |
|
|---|---|---|---|
| Benefits summary | HMO 1500 Deductible |
HMO 2500 Deductible |
HMO 5000 Deductible |
| Office visit | $30 | $30 | $30 |
| Specialist visit | $50 | $50 | $50 |
| Hospitalization | 30% coinsurance, after deductible | 30% coinsurance, after deductible | 30% coinsurance, after deductible |
Personal Choice PPO cost-saving options
| PPO 2500 Deductible | PPO 5000 Deductible | PPO 3000 HSA | PPO 5000 HSA | PPO 8000 Deductible | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Benefits summary | PPO 2500 Deductible |
PPO 5000 Deductible |
PPO 3000 HSA |
PPO 5000 HSA |
PPO 8000 Deductible |
|||||
| Location | In-network (you pay) | Out-of-network (you pay) | In-network (you pay) | Out-of-network (you pay) | In-network (you pay) | Out-of-network (you pay) | In-network (you pay) | Out-of-network (you pay) | In-network (you pay) | Out-of-network (you pay) |
| Office Visit | $30, no deductible | 50%, after deductible | $30, no deductible | 50%, after deductible | 20% after deductible | 50%, after deductible | $0, after deductible | 50%, after deductible | $25, no deductible | 50%, after deductible |
| Specialist Visit | $50, no deductible | 50%, after deductible | $50, no deductible | 50%, after deductible | 20%, after deductible | 50%, after deductible | $0, after deductible | 50%, after deductible | 20%, after deductible | 50%, after deductible |
| Hospitalization | 20%, after $2,500 deductible; unlimited days | 50%, after deductible/ 70 days | 20%, after $5,000 deductible; unlimited days | 50%, after deductible/ 70 days | 20%, after deductible; unlimited days | 50%, after deductible/ 70 days | $0, after deductible; unlimited days | 50%, after deductible/ 70 days | 20%, after $8,000 deductible; unlimited days | 50%, after deductible/ 70 days |
Once you have determined which plan is right for you, fill out the Plan Change Request Form. Sign and return the form to the address below or fax to 215-238-7067. For your new plan to be reflected in your next invoice, IBC must receive your completed plan change request form by June 4, 2012.
Independence Blue Cross
P.O. Box 41452
Philadelphia, PA 19101
Fax: 215-238-7067
If you have other questions concerning this rate adjustment, please call us at 1-888-249-2118 .