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Keystone HMO Gold Proactive
Plan Summary
Plan Type HMO
Office Visit for Primary Doctor
Find Doctors 		Tier 1: $15 Copay
Tier 2: $30 Copay
Office Visit for Specialist Tier 1: $40 Copay
Tier 2: $60 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) Tier 1: $15 Copay
Tier 2: $30 Copay
Annual Deductible None
Separate Prescription Drugs Deductible $0 per person | $0 per group
Coinsurance Tier 1: 0%
Tier 2: 20%
Retail Prescription Drugs Generic Drugs: $3 Copay;
Preferred Brand Drugs: $100 Copay;
Non-Preferred Brand Drugs: 50% Coinsurance;
Specialty Drugs: 50% Coinsurance;
Annual Out-of-Pocket Limit Individual: $9,200
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage No 
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $400 Copay
Emergency Ambulance Services $150 Copay
Urgent Care Facility $40 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $3 Copay;
Preferred Brand Drugs: $100 Copay;
Non-Preferred Brand Drugs: 50% Coinsurance;
Specialty Drugs: 50% Coinsurance;
Separate Prescription Drugs Deductible $0 per person | $0 per group
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
Tier 1: $5 Copay
Tier 2: $50 Copay
Outpatient Facility Fee:
Tier 1: $150 Copay
Tier 2: $550 Copay
Outpatient Lab/X-Ray Outpatient Lab:
No Charge
X-rays:
$60 Copay
Imaging (CT and PET scans, MRIs) $120 Copay
Outpatient Mental Health $40 Copay
Outpatient Substance Abuse $40 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $60 Copay, limited to 30 Visit(s) per Benefit Period
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
Tier 1: $350 Copay per Day
Tier 2: $700 Copay per Day, A copay is required for up to 5 days
Inpatient Physician and Surgical Services:
Tier 1: No Charge
Tier 2: 20% Coinsurance
Skilled Nursing Facility $175 Copay per Day, A copay is required for up to 5 days; limited to 120 Days per Benefit Period
Inpatient Mental Health $350 Copay per Day, A copay is required for up to 5 days
Inpatient Substance Abuse $350 Copay per Day, A copay is required for up to 5 days
Home Healthcare Tier 1: No Charge, limited to 60 Visit(s) per Benefit Period
Tier 2: $100 Copay, limited to 60 Visit(s) per Benefit Period
Maternity Coverage
Pre & Postnatal Office Visit Tier 1: $40 Copay
Tier 2: $60 Copay
Labor & Delivery Hospital Stay Tier 1: $350 Copay per day
Tier 2: $700 Copay per day, A copay is required for up to 5 days
Pediatric Services
Dental Checkup for Children No Charge, limited to 1 Exam(s) per 6 Months
Vision Screening for Children No Charge, limited to 1 Exam(s) per Year
Eye Glasses for Children No Charge, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) 50% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage $50 Copay, limited to 20 Visit(s) per Benefit Period
Durable Medical Equipment 50% Coinsurance
Hospice No Charge
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating NR as of 11/22/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure (Not available)

The carrier has not provided a separate document for Exclusions and Limitations.

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
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  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.