Keystone HMO Silver Proactive Lite

Health Insurance Plan Details (2025 Plan)

by Independence Blue Cross

Monthly Premium

HMO
$ubsidy
Silver
Deductible
$2,000 /yr
Max Out-of-Pocket
$9,200 /yr

Details

Deductible (per individual) $2,000 /yr
Deductible (per family) $4,000 /yr
Max Out-of-Pocket (per individual) $9,200 /yr
Max Out-of-Pocket (per family) $18,400 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type HMO
Includes Child Dental? Yes
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $50 Copay
Specialist Visit $90 Copay
Emergency Room $950 Copay
Inpatient Facility $600 Copay per Day with deductible
Inpatient Physician Not Applicable
Drug Costs
Generic Drugs $5 Copay
Preferred Brand Drugs $90 Copay after deductible
Non-preferred Brand Drugs 50.00% Coinsurance after deductible
Specialty Drugs 50.00% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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