Keystone Health Plan East (HMO) — HCR 100% Preventive Options: Groups 51+IBC Forms Online — Benefit Summaries

Notice!

Benefit summaries have been updated to reflect 100% Preventive values in alignment with Health Care Reform.

PDF icon Forms are in pdf format.

Option	PCP Copay	Last Updated
Keystone Student Select	$10	2011-09
Keystone 105	$ 5	2011-09
Keystone 10	$10	2011-09
Keystone 15	$15	2011-09
Keystone 2	$ 2	2011-09
Keystone 505	$ 5	2011-09
Keystone 510	$10	2011-09
Keystone 515	$15	2011-09
Flex HMO C1-F1	$10	2011-09
Flex HMO C1-F2	$10	2011-09
Flex HMO C1-F3	$10	2011-09
Flex HMO C1-F4	$10	2011-09
Flex HMO C2-F1	$15	2011-09
Flex HMO C2-F2	$15	2011-09
Flex HMO C2-F3	$15	2011-09
Flex HMO C2-F4	$15	2011-09
Flex HMO C3-F1	$20	2011-09
Flex HMO C3-F2	$20	2011-09
Flex HMO C3-F3	$20	2011-09
Flex HMO C3-F4	$20	2011-09
Flex HMO C3-F5	$20	2011-09
Flex HMO C4-F3	$30	2011-09
Flex HMO C4-F4	$30	2011-09
Flex HMO C4-F5	$30	2011-09
Flex HMO D1-N1	$20	2011-09
Flex HMO D1-N2	$20	2011-09
Flex HMO D2-N1	$20	2011-09
Flex HMO D2-N2	$20	2011-09
Flex HMO D3-N1	$20	2011-09
Flex HMO D3-N2	$20	2011-09
Flex HMO D4-N1	$20	2011-09
Flex HMO D4-N2	$20	2011-09
Keystone Select	$10	2011-09
Keystone Select II	$15	2011-09
Keystone Select III	$20	2011-09
Keystone Select IV	$20	2011-09
Keystone Student 515	$15	2011-09
Flex Student Series C3-F4	$20	2011-09
Flex Student Series D1-N2	$20	2011-09
Flex Student Series D2-N2	$20	2011-09
Keystone Student Select II	$15	2011-09
Keystone 5	$ 5	2011-09