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Benefits Summary

Keystone Health Plan East HMO

Benefits Keystone 5 Keystone 15 Keystone Select III
Deductible NONE NONE NONE
Overall Lifetime Maximum Unlimited Unlimited Unlimited
Office Visit (PCP) $5 $15 $20
Specialist Visit $5 $25 $25
Hospital Care (Inpatient/Outpatient) 100% 100% $125/day $625 maximum/inpt adm $100 copay per outpt surgery
Outpatient Rehabilitation Therapy 100% (up to 60 consecutive days/condition) 100% (up to 60 consecutive days/condition) $25 copay (up to 60 consecutive days/condition)*
X-ray 100% 100% $25 copay *
Lab 100% 100% 100%
Preventive Care $5 $10 $20
Routine Gyn $5 $25 $25
Maternity Care $5 (1st visit only) 100% thereafter $25 (1st visit only) 100% thereafter $25 (1st visit only) 100% thereafter
Emergency Care $35 (waived if admitted) $35 (waived if admitted) $50 (waived if admitted)

* This benefit plan applies copays to physical, occupational, and speech therapy visits, and X-rays.

For more information on the terms, limitations, and exclusions of the benefit programs, please contact your independent broker or our Marketing Department at 215-241-3400.

The above table illustrates some of the benefit programs available. This managed care plan may not cover all your health care expenses. This information has been extracted from and is subject to the terms and conditions of all applicable group contracts and member handbooks.