Keystone HMO Silver Basic – HMO
94% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $30 copay
Urgent care visit: 10% coinsurance
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $1,500 per person $3,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 10% coinsurance |
| Emergency room | $50 copay |
| Ambulance | 10% coinsurance |
| Hospital stay (facility) | 10% coinsurance |
| Hospital stay (physician) | 10% coinsurance |
| Outpatient procedure (facility) | $75 copay |
| Outpatient procedure (physician) | $25 copay |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $4 copay |
| Brand | 5% coinsurance |
| Non-preferred Brand | 15% coinsurance |
| Specialty | 50%, up to $1,000 copay, 50%, up to $1,000 coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $15 copay |
| Imaging (CT/PET/MRI) | $30 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 10% coinsurance |
