Flex Copay Series Office/Outpatient Care

Select copay option for network doctor's office visits, therapies and diagnostic care.

Office/Outpatient Care	C1	C2	C3	C4¹
Doctor's Office Visits
Primary and OB/GYN Care	$10	$15	$20	$30
Specialist	$20	$30	$40	$50
Physical/Occupational Therapy
(30 visits per cal. year²)	$20	$30	$40	$50
Spinal Manipulations and Speech Therapy
(20 visits each per cal. year²)	$20	$30	$40	$50
Cardiac and Pulmonary Rehabilitation
(36 sessions each per cal year²)	$20	$30	$40	$50
X-Ray/Radiology/Diagnostics
Routine Radiology	$20	$30	$40	$50
MRI/MRA, CT Scans, PET Scans³	$40	$60	$80	$100
Injectable Medications
Standard Injectables	$0	$0	$0	$0
Biotech/Specialty Injectables³	$50	$75	$100	$125
Lab/Pathology
Copayment:	$0	$0	$0	$0

¹C4 can only be paired with F3, F4, or F5.
²For Personal Choice, combined in/out-of-network maximum.
³Pre-authorization required.

All enrollments subject to underwriting guidelines. The plans outlined represent only a partial listing of benefits. These managed care plans may not cover all of your health care expenses. Read your contract/member handbook carefully to determine which health care services are covered. If you need more information, please call 215-241-3400.

The percentage for in-network and out-of-network reimbursement shown represents a percentage of the Plan allowance, not the provider's actual charge. For more information about the Plan allowance in the Personal Choice, Keystone Direct POS (out-of-network) benefits and self-referred portion of the Keystone Point-of-Service programs, see the definition of covered expense in your Personal Choice or Comprehensive Major Medical group contract. Out-of-network providers may also bill a member for the difference between the Plan allowance, which is the amount paid by the Plan, and the provider's actual charge. This difference may be significant.