| Benefits |
Keystone
Point-of-Service
5/B |
Keystone
Point-of-Service
15/E |
Keystone
Point-of-Service
Select lll/G |
| |
Referred |
Self-
Referred |
Referred |
Self-
Referred |
Referred |
Self-
Referred |
| Deductible |
NONE |
$200 Indiv.
$600 Family |
NONE |
$500 Indiv.
$1500 Family |
NONE |
$1000 Indiv.
$3000 Family |
| Out-of-Pocket Maximum |
$650/member |
$1000 Indiv. $3000 Family |
$1000 Indiv. $2000 Family |
$3000 Indiv. $6000 Family |
$2000 Indiv. $4000 Family |
$10,000 Indiv. $30,000 Family |
| Overall Lifetime Maximum |
Unlimited |
$1,000,000 |
Unlimited |
$1,000,000 |
Unlimited |
$1,000,000 |
| Office Visit (PCP) |
$5 |
80% |
$15 |
70% |
$20 |
60% |
| Specialist Visit |
$5 |
80% |
$25 |
70% |
$25 |
60% |
| Hospital Care (Inpatient/ Outpatient) |
100% |
80% |
100% |
70% |
$125/day
$625 max/
inpatient admission
$100 copay/ outpatient surgery |
60% |
| Outpatient Rehabilitation Therapy |
100%
(up to 60 consecutive days/
condition) |
80% |
100%
(up to 60 consecutive days/
condition) |
70% |
$25
(up to 60 consecutive days/
condition)* |
60% |
| X-ray |
100% |
80% |
100% |
70% |
$25* |
60% |
| Lab |
100% |
80% |
100% |
70% |
100% |
60% |
| Preventive Care |
$5 |
80% |
$15 |
70% |
$20 |
60% |
| Maternity Care |
$5
(1st visit) 100% thereafter |
80% |
$25
(1st visit) 100% thereafter |
70% |
$25
(1st visit) 100% thereafter |
60% |
| Emergency Care |
$35
(waived if admitted) |
$35
(waived if admitted) |
$35
(waived if admitted) |
$35
(waived if admitted) |
$50
(waived if admitted) |
$50
(waived if admitted) |
The above table illustrates some of the benefit programs available. This information has been extracted from and is subject to the terms and conditions of all applicable group contracts and member handbooks. These managed care plans may not cover all your expenses. Read your contract carefully.
