Keystone HMO Silver Proactive Essential – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $5,000 per person $5,000 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | $975 copay |
| Ambulance | $200 copay |
| Hospital stay (facility) | first 5 day(s) $600 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $250 copay after deductible |
| Outpatient procedure (physician) | $5 copay after deductible |
| Physical rehabilitation | $100 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $600 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 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 | $150 copay |
| Imaging (CT/PET/MRI) | $300 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $100 copay |
| Psychiatric hospital stay | first 5 day(s) $600 per day then $0 copay after deductible |
