Eligibility		How to Access		More Info
Allergy Testing and Treatment		Provided or referred by primary care physician		Covered Services: Outpatient Covered Services: Inpatient
Ambulance Services		Provided or referred by primary care physician Preapproval required, unless an emergency		Covered Services: Outpatient
Anesthesia		Provided or referred by primary care physician		Covered Services: Outpatient Covered Services: Inpatient
Autologous Blood Drawing/Storage/Transfusion		Provided or referred by primary care physician		Covered Services: Outpatient Covered Services: Inpatient
Cardiac Rehabilitation Therapy		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Chemotherapy		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Diabetic Self-Management and Education		Provided or referred by primary care physician		Covered Services: Outpatient
Diabetic Supplies		Covered 100% when provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Diagnostic Laboratory and X-Ray Services		Provided or referred by primary care physician		Covered Services: Outpatient
Dialysis		Provided or referred by primary care physician		Covered Services: Outpatient Covered Services: Inpatient
Doctor Office Visits		Provided or referred by primary care physician		Covered Services Covered Services: Outpatient
Emergency Care		Call 911 or go immediately to the emergency department of the closest hospital		Using Your Insurance Using Your Insurance
Genetic Testing and Counseling		Provided or referred by primary care physician		Covered Services: Outpatient
Gynecological Care		Primary care physician or participating gynecologist No referral necessary		Using Your Insurance Covered Services: Outpatient
Home Health Care		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient
Home Visits		Provided or referred by primary care physician		Covered Services: Outpatient
Hospice Care		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Hospital Services		Provided or referred by primary care physician Needs preapproval by Keystone		Using Your Insurance Covered Services: Inpatient
Illness (treatment for)		Provided or referred by primary care physician		Covered Services
Immunizations (shots)		Provided by primary care physician		Covered Services Covered Services: Outpatient
Infusion Therapy		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient
Injections		Provided by primary care physician Preapproval, when required		Covered Services: Outpatient
Insulin and Oral Agents		Covered 100% when prescribed by primary care physician or referred specialist		Covered Services: Outpatient
Mammogram Screening		No referral necessary		Covered Services: Outpatient
Mastectomy Care		Provided or referred by primary care physicianor participating gynecologist		Covered Services: Inpatient
Maternity Care		Primary care physician or participating obstetrician/gynecologist; No referral necessary		Covered Services: Outpatient
Medical Foods		Ordered by primary care physician or referred specialist Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Newborn Care		Coverage of an enrolled female adultBasic member’s newborn is provided for up to 31 days following birth		Covered Services: Outpatient Covered Services: Inpatient
Obstetrical Care		Primary care physician or participating obstetrician No referral necessary		Using Your Insurance Covered Services: Outpatient Covered Services: Inpatient
Office Visits		Provided or referred by primary care physician		Using Your Insurance Covered Services Covered Services: Outpatient
Oral Surgery		Limited procedures covered Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Organ Transplants		Referred by primary care physician Needs preapproval by Keystone		Covered Services: Inpatient
Orthotics		Referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient
Pap Smears		Provided by primary care physician or participating gynecologist		Covered Services Covered Services: Outpatient
Podiatric Care		Referred by primary care physician		Covered Services: Outpatient
Primary and Preventive Health Services		Provided by primary care physician or participating gynecologist		Covered Services Covered Services: Outpatient
Prosthetic Devices		Referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Pulmonary Rehabilitation Services		Referred by primary care physician Treatment for up to 60 days Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Radiation Therapy		Provided or referred by primary care physician		Covered Services: Outpatient Covered Services: Inpatient
Reconstructive Surgery		Covered following a medically necessary covered surgical procedure Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Referral to a Specialist		Provided by primary care physician		Using Your Insurance Using Your Insurance Covered Services: Outpatient Covered Services: Inpatient
Rehabilitation Therapy (occupational, physical, hand and speech)		Provided or referred by primary care physician Treatment for up to 60 days per episode for each therapy Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Respiratory Therapy		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Skilled Nursing Facility		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Inpatient
Specialist Services		Referred by primary care physician		Using Your Insurance Using Your Insurance Covered Services: Outpatient Covered Services: Inpatient
Spinal Manipulation Services		Provided or referred by primary care physician or referred specialist Not covered when provided by a chiropractor Needs preapproval by Keystone		Covered Services: Outpatient
Surgery		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Termination of Pregnancy		Primary care physician or participating gynecologist Covered only when necessary to prevent the death of the woman or in the case of rape or incest. Elective abortions are not covered. Needs preapproval by Keystone		Covered Services: Outpatient
Urgent Care		Provided by primary care physician		Using Your Insurance