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Keystone Health Plan East (HMO) — Groups 2–50IBC Forms Online — Benefit Summaries
These summaries include medical benefits only, but have been named so that you can reference the appropriate corresponding drug and vision benefit summaries.
Forms are in pdf format.
| Option | PCP Copay | Last Updated |
|---|---|---|
| HMO 1 rx 10/20/35 vision $100 | $10 | 2012-03 |
| HMO 2 rx 10/20/35 vision $100 | $15 | 2012-03 |
| HMO 3 rx 7/50/125 vision $100 | $20 | 2012-03 |
| HMO 4 rx 7/50/125 vision $100 | $20 | 2012-03 |
| HMO 5 rx 7/50/125 vision $100 | $30 | 2012-03 |
| HMO 6 rx 250/20/40/60 vision $100 | $20 | 2012-03 |
| HMO 7 rx 250/20/40/60 vision $100 | $20 | 2012-03 |
| HMO 1.1 rx 10/40/70 vision $100 | $10 | 2012-03 |
| HMO 2.1 rx 10/40/70 vision $100 | $15 | 2012-03 |
| HMO 3.1 rx 10/45/75 vision $100 | $20 | 2012-03 |
| HMO 4.1 rx 10/45/75 vision $100 | $20 | 2012-03 |
| HMO 5.1 rx 10/45/75 vision $100 | $30 | 2012-03 |
| HMO 6.1 rx 10/45/75 vision $100 | $20 | 2012-03 |
| HMO 7.1 rx $4 generic only vision $100 | $20 | 2012-03 |
