Keystone Health Plan East Standard Option HMO

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The Keystone Standard Option plan is a health maintenance organization (HMO). This means that your primary care physician (PCP) coordinates all of your medical needs within the Keystone network of providers. Your PCP also refers most of your specialty care needs.

With Keystone HMO Standard Option, you have higher out-of-pocket costs along with a deducible and coinsurance.

Features of Keystone HMO Standard Option

$20 copay for PCP office visits; $40 copay for specialists
$500 (calendar year) deductible for individuals; $1,500 for a family
20% coinsurance, after you have met your deductible, for some services.*
An extensive network of over 30,000 doctors and nearly 200 hospitals
Referrals for specialty care are coordinated by your PCP
Direct Access OB/GYNsm — no referrals required to see a network OB/GYN for routine or maternity care**
Wellness programs, including fitness reimbursement and discounts on alternative health care services, at no additional cost
Programs to manage chronic conditions
Excellent NCQA accreditation — Keystone has received the highest standard of measurement from NCQA
Comprehensive benefits for students and travelers out of the area

Download the Keystone FEHBP 2008 OPM brochure.

Benefits and Services	Coverage
Doctor’s Visits	You Pay
Office visits with your Primary Care Physician	Covered 100% — with a $20 copayment	When you join Keystone, you’ll meet with private-practice physicians in their own offices. Included in office visits are physical examinations, treatment for routine illness and injury, and immunizations.
Office visits to a Referred Specialist	Covered 100% — with a $40 copayment
Hospital Care	You Pay
Unlimited inpatient stay and surgery	20% after deductible (calendar year) Individual $500 Family $1500	In-hospital care includes semi-private room and board, complete medical and surgical care, all testing and diagnostic services and consultations. And don't forget...after a hospital visit you won't have any confusing claim forms to complete.
Emergency Care	You Pay
Treatment in any hospital emergency room	20% after deductible (calendar year) Individual $500 Family $1500	Emergency care is covered 24 hours-a-day, 7 days-a-week, in any hospital.
Preventive Health Services	You Pay
Routine gynecological care without a referral (provided through a participating Keystone OB/GYN)	Covered 100% — with a $40 copayment	In addition to covering eye examinations 100%, Keystone also reimburses you up to $35 once every two calendar years for prescription eyeglasses or contact lenses.
Hearing examinations	Covered 100% — with a $20 copayment
Allergy Immunizations	Covered 100% — with office visit copayment
Eye Examinations	Covered 100% — with a $40 copayment
Maternity Care	You Pay
Obstetric care, including prenatal and postnatal care	Covered 100% — with a $20 copayment for first office visit. Subsequent visits are covered at 100%.	Keystone’s innovative Baby BluePrints® program will also provide expectant mothers with comprehensive prenatal care.
Dental Care	You Pay
Oral exams (once every six months) Teeth cleaning (once every six months) X-Rays Surface fillings	Covered 100% — with a $5 copayment	Keystone provides coverage for the entire family!
Prescriptions	You Pay
Generic Formulary Copayment	$20 for up to a 30-day supply	Keystone does not require you to pre-select a pharmacy. In fact, you can get discounted prescription drugs at thousands of pharmacies both locally and nationwide.
Brand Formulary Copayment	$40 for up to a 30-day supply
Non-Formulary Copayment	$60 for up to a 30-day supply
Mail order option	Two times the appropriate retail copayments (as shown above) for up to a 90-day supply of maintenance medications
Mental Health and Substance Abuse	You Pay
Professional Services	You pay just $40	Your cost sharing responsibilities are no greater than for other illnesses or conditions.
Hospital or other facility care	20% after deductible (calendar year) Individual $500 Family $1,500

Questions? For more information on Keystone Health Plan East, call toll free 1-800-557-FEDS.

*Please refer to the 2008 Keystone Health Plan East FEHBP Brochure for complete benefit information.
**Non-routine care provided by Reproductive Endocrinologists/Infertility Specialists and Gynecologic Oncologists continues to require a referral form from your primary care physician.

The plan outlined on this page represents only a partial listing of benefits.
The information on this page has been extracted from, and is subject to the terms and conditions of, all applicable Keystone group contracts and the Federal Brochure and related materials.