Flex Copay Series Out-of-Network Benefits

Select out-of-network benefits. (Keystone Point of Service, Keystone Direct POS and Personal Choice options only)

Out-of-Network Benefits	O1	O2
Deductible Individual/Family	$500/$1,500	$1,500/$4,500
Coinsurance	70% of plan allowance³	50% of plan allowance
Out-of-Pocket Maximum Individual/Family	$3,000/$9,000	$10,000/$30,000
Overall Lifetime Maximum	$1,000,000	$500,000
Office Visits
Doctor's Office Visits Primary and OB/GYN Care Specialist	70% 70%	50% 50%
Physical/Occupational Therapy (30 visits per cal. year¹)	70%	50%
Spinal Manipulations and Speech Therapy (20 visits each per cal. year¹)	70%	50%
Cardiac and Pulmonary Rehabilitation (36 sessions each per cal. year¹)	70%	50%
X-Ray/Radiology/Diagnostics²	70%	50%
Injectable Medications²	70%	50%
Lab/Pathology	70%	50%
Facility/Ancillary
Hospital Inpatient² (70 days out-of-network/self-referred)	70%	50%
Outpatient Surgery²	70%	50%
Skilled Nursing Facility² (PPO: 120 days per cal. year¹; POS and Direct POS: 60 days per cal. year)	70%	50%
Emergency Room (Copay not waived, if admitted)	Covered at in-network level.
Outpatient Private Duty Nursing² (360 hours per cal. year*)	70%	50%
Prosthetics and Durable Medical Equipment (DME)² (DME $2,500 maximum per cal. year)	50%	50%

Coinsurance is based upon Plan allowance and reflects amount paid by the Plan.

¹For Personal Choice, combined in/out-of-network maximum.
²Pre-authorization required for certain services.
³Prosthetics and DME are covered at a 50% coinsurance level.