Cost of Common Procedures
The Department of Public Welfare would like you to have an idea of what your health plan pays for common medicines and procedures.
The charts, below, will help you to know what Keystone Mercy pays on an average for medicines and dental procedures.
Pharmacy:
| Generic Drug Name |
Average Amount We Paid the Pharmacy
for the Generic Drug to be filled |
| Omeprazole (Brand Name is Prilosec) |
$20.70 |
| ALBUTEROL (Brand Name is Ventoline HFA) |
$33.56 |
| Loratadine (Brand Name is Claritin) |
$8.11 |
| AMOXICILLIN (Brand Name is Amoxil) |
$8.00 |
| Oxycodone or Hydrocodone w/ Acetaminophen ( Brand Name is Percocet or Vicodin) |
$7.50-$9.00 |
Dental:
| Name of Dental Procedure |
Average Cost that Health Plan
Pays the Dentist |
| Sealant |
$25.00 |
| Oral Evaluation |
$20.00 |
| Fluoride - Child |
$17.00 |
| Tooth Removal |
$45.00 |
| Oral Exam |
$20.00 |
| Oral X-Ray |
$12.00 |
| Cleaning - Adult |
$34.00 |
| Cleaning - Child |
$22.00 |
| Filling |
$45.00 |
|
