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General
Account Installation Forms
Health Accounts
Benefit Summary Grids
Blue Solutions: Groups 2-50
HMO
POS/DPOS
Personal Choice
Blue Solutions: Groups 51-99
Large Group Options 100+
Dental
Broker Toolkit
Keystone Health Plan East (HMO)
Groups 2 – 50
Benefits
|
Contracts
Forms are in pdf format.
Blue Solutions
Option
PCP Copay
HMO 1 Rx $10/$20/$35 Vision $100
$10
HMO 2 Rx $10/$20/$35 Vision $100
$15
HMO 3 Rx $7/50%/$125 Vision $100
$20
HMO 4 Rx $7/50%/$125 Vision $100
$20
HMO 5 Rx $7/50%/$125 Vision $100
$30
HMO 6 Rx $250/$20/$40/$60 Vision $100
$20
HMO 7 Rx $250/$20/$40/$60 Vision $100
$20
HMO 1.1 Rx $10/$40/$70 Vision $100
$10
HMO 2.1 Rx $10/$40/$70 Vision $100
$15
HMO 3.1 Rx $10/$45/$75 Vision $100
$20
HMO 4.1 Rx $10/$45/$75 Vision $100
$20
HMO 5.1 Rx $10/$45/$75 Vision $100
$30
HMO 6.1 Rx $250/$10/$45/$75 Vision $100
$20
HMO 7.1 Rx $4 generic only Vision $100
$20
Blue Solutions Choice
Option
PCP Copay
BC HMO 1.1 Rx $10/$40/$70 Vision $100
$10
BC HMO 2.1 Rx $10/$40/$70 Vision $100
$15
BC HMO 3 Rx $7/50% ($125) Vision $100
$20
BC HMO 4 Rx Rx $7/50% ($125) Vision $100
$20*
BC HMO 5 Rx $7/50% ($125) Vision $100
$30
BC HMO 6 Rx $250/$20/$40/$60 Vision $100
$20*
BC HMO 7.2 Rx $7/50% ($125) Vision $100
$20*
* no deductible