Keystone HMO Silver Basic – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $80 copay
Urgent care visit: 50% after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $5,500 per person $5,500 per person |
| Out-of-pocket max | $9,000 per person $18,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 50% after deductible |
| Emergency room | $600 copay |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | $1,650 copay after deductible |
| Outpatient procedure (physician) | $120 copay after deductible |
| Physical rehabilitation | $80 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible, up to $1,000 copay, 50% after deductible, up to $1,000 |
Lab Tests and Diagnostic Procedures
| X-rays | $175 copay |
| Imaging (CT/PET/MRI) | $350 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $80 copay |
| Psychiatric hospital stay | 50% after deductible |
