Keystone Health Plan East (HMO)Groups 100+

Forms are in pdf format.

Option	PCP Copay
Keystone 2	$2
Keystone 5	$5
Keystone 105	$5
Keystone 505	$5
Keystone 510	$10
Keystone 10	$10
Keystone Select	$10
Keystone 15	$15
Keystone Select II	$15
Keystone 515	$15
Keystone Select III	$20
Keystone Select IV	$20
Flex HMO C1-F1	$10
Flex HMO C1-F2	$10
Flex HMO C1-F3	$10
Flex HMO C1-F4	$10
Flex HMO C2-F1	$15
Flex HMO C2-F2	$15
Flex HMO C2-F3	$15
Flex HMO C2-F4	$15
Flex HMO C3-F1	$20
Flex HMO C3-F2	$20
Flex HMO C3-F3	$20
Flex HMO C3-F4	$20
Flex HMO C3-F5	$20
Flex HMO D1-N1	$20
Flex HMO D1-N2	$20
Flex HMO D2-N1	$20
Flex HMO D2-N2	$20
Flex HMO D3-N1	$20
Flex HMO D3-N2	$20
Flex HMO D4-N1	$20
Flex HMO D4-N2	$20
Flex HMO C4-F3	$30
Flex HMO C4-F4	$30
Flex HMO C4-F5	$30
Keystone Student Select	$10
Keystone Student 515	$15
Keystone Student Select II	$15
Flex Student Series C3-F4	$20
Flex Student Series D1-N2	$20
Flex Student Series D2-N2	$20