Keystone Point of Service (POS) — 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.

PDF icon Forms are in pdf format.

Option PCP Copay Last Updated
Direct POS 1 rx 10/20/35 vision $100 $20 2012-03
Direct POS 2 rx 10/20/35 vision $100 $10 2012-03
Direct POS 3 rx 10/20/35 vision $100 $15 2012-03
Direct POS 4 rx 7/50/125 vision $100 $20 2012-03
Direct POS 5 rx 7/50/125 vision $100 $30 2012-03
Direct POS 6 rx 250/20/40/60 vision $100 $20 2012-03
Direct POS 7 rx 250/20/40/60 vision $100 $20 2012-03
Direct POS 1.1 rx 10/40/70 vision $100 $10 2012-03
Direct POS 2.1 rx 10/40/70 vision $100 $15 2012-03
Direct POS 3.1 rx 10/40/70 vision $100 $20 2012-03
Direct POS 4.1 rx 10/45/75 vision $100 $20 2012-03
Direct POS 5.1 rx 10/45/75 vision $100 $30 2012-03
Direct POS 6.1 rx 10/45/75 vision $100 $20 2012-03
Direct POS 7.1 rx $4 generic only vision $100 $20 2012-03