Keystone HMO Silver Basic – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: 30% after deductible
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $2,750 per person $5,500 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 30% after deductible |
| Emergency room | $250 copay |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | $1,000 copay after deductible |
| Outpatient procedure (physician) | $70 copay after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 40% 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 | $75 copay |
| Imaging (CT/PET/MRI) | $150 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 30% after deductible |
