Keystone HMO Gold Classic – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $80 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $500 per person $500 per person |
| Out-of-pocket max | $8,000 per person $16,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $80 copay |
| Emergency room | $500 copay |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | $300 copay |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | $80 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $100 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50%, up to $1,000 copay, 50%, up to $1,000 coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $65 copay |
| Imaging (CT/PET/MRI) | $125 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $80 copay |
| Psychiatric hospital stay | 20% after deductible |
