Flex Copay Series Office/Outpatient Care
Select copay option for network doctor's office visits, therapies and diagnostic care.
|Doctor's Office Visits|
|Primary and OB/GYN Care||$10||$15||$20||$30|
|(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|
|MRI/MRA, CT Scans, PET Scans³||$40||$60||$80||$100|
¹C4 can only be paired with F3, F4, or F5.
²For Personal Choice, combined in/out-of-network maximum.
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.