Keystone Health Plan East Standard Option HMO

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

Features of Keystone Standard Option HMO

  • $20 copay for PCP office visits and $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 more than 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 2009 OPM brochure.

Benefits and Services Coverage
Doctor’s Visits
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
Unlimited inpatient stay and surgery You pay an inpatient hospital coinsurance of 20% after a deductible of:
• $500 — individual
• $1,500 — family
(per calendar year)		 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
Treatment in any hospital emergency room You pay an inpatient hospital coinsurance of 20% after a deductible of:
• $500 — individual
• $1,500 — family
(per calendar year)		 Emergency care is covered 24 hours-a-day, 7 days-a-week, in any hospital.
Preventive Health Services
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
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
Oral exams
(once every six months) 		Covered 100% —
with a $5 copayment.		 Keystone provides coverage for the entire family.

Teeth cleaning
(once every six months)

X-rays

Surface fillings
Prescriptions

Generic Formulary
Copayment

 You pay $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		 You pay $40 for up to a 30-day supply.
Non-Formulary
Copayment		 You pay $60 for up to a 30-day supply.
Mail order option

You pay two times the appropriate retail copayments (as shown above) for up to a 90-day supply of maintenance medications.
Mental Health and Substance Abuse
Professional Services You pay just $40. Your cost sharing responsibilities are no greater than for other illnesses or conditions.
Hospital or other facility care You pay an inpatient hospital coinsurance of 20% after a deductible of:
• $500 — individual
• $1,500 — family
(per calendar year)

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

*Please refer to the 2009 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.