Benefit		How to Access		More Info
Allergy Testing and Treatment		Provided or referred by primary care physician		Primary & Preventive Care 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 Needs preapproval by Keystone		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
Dental		Provided by any participating United Concordia Dentist		Benefits
Diabetic Self-Management and Education		Provided or referred by primary care physician		Covered Services: Outpatient
Diabetic Supplies		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		Primary & Preventive Care Primary & Preventive Care Covered Services: Outpatient
Durable Medical Equipment		Preapproval, when required. Must be purchased through a participating DME provider.		Covered Services: Outpatient
Emergency Care		Call 911 or go immediately to the emergency department of the closest hospital		Using Your Child's Insurance
Genetic Testing		Provided or referred by the primary care physician		Covered Services: Outpatient
Gynecological Care		Primary care physician or participating gynecologist No referral necessary		Using Your Child's Insurance Primary & Preventive Care Covered Services: Outpatient
Hearing Care		Provided or referred by primary care physician		Primary & Preventive Care Covered Services: Outpatient
Home Health Care		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient
Home Infusion		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
Hospital Services		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Inpatient
Illness (treatment for)		Provided or referred by primary care physician		Primary & Preventive Care
Immunizations (shots)		Provided by primary care physician		Primary & Preventive Care Primary & Preventive Care Covered Services: Outpatient
Injections		Provided by primary care physician Preapproval, when required		Covered Services: Outpatient
Injuries (treatment for)		Provided or referred by primary care physician, unless life- or limb-threatening *If life- or limb-threatening seek care immediately.		Primary & Preventive Care
Lab Work		Provided or referred by primary care physician		Covered Services: Outpatient
Mammogram Screening		Referred by primary care physician or participating obstetrical/gynecological specialist		Using Your Child's Insurance Covered Services: Outpatient
Maternity Care		Primary care physician or participating obstetrician/gynecologist; No referral necessary		Using Your Child's Insurance Covered Services: Outpatient
Medical Foods		Ordered by primary care physician or referred specialist Needs preapproval by Keystone		Covered Services: Outpatient Covered Services: Inpatient
Mental Health Services		Provided by Magellan Behavioral Health Services, Inc. Call 1-800-294-0800 for services		Benefits
Newborn Care		Provided by a participating pediatrician		Covered Services: Outpatient Covered Services: Inpatient
Obstetrical Care		Primary care physician or participating obstetrician No referral necessary		Using Your Child's Insurance Covered Services: Outpatient Covered Services: Inpatient
Office Visits		Provided or referred by primary care physician		Primary & Preventive Care Primary & Preventive Care Covered Services: Outpatient
Oral Surgery		Provided or referred by primary care physician 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		Using Your Child's Insurance Primary & Preventive Care Covered Services: Outpatient
Physical Examinations		Provided by primary care physician		Primary & Preventive Care Primary & Preventive Care
Podiatric Care		Referred by primary care physician		Covered Services: Outpatient
Prenatal and Obstetrical Care		Primary care physician or participating obstetrician/gynecologist; No referral necessary.		Using Your Child's Insurance Covered Services: Outpatient Covered Services: Inpatient
Prescription Drugs		Any participating pharmacy		Benefits
Primary and Preventive Health Services		Provided by primary care physician or participating gynecologist		Primary & Preventive Care Primary & Preventive Care 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
Referral to a Specialist		Provided by primary care physician		Using Your Child's Insurance Using Your Child's 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 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
Routine Pediatric Care		Provided by primary care physician		Primary & Preventive Care Primary & Preventive Care
Serious Mental Illness Health Care		Provided by Magellan Behavioral Health Services, Inc. Call 1-800-294-0800 for services		Benefits
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 Child's Insurance Using Your Child's Insurance Covered Services: Outpatient Covered Services: Inpatient
Spinal Manipulation Services		Provided or referred by primary care physician Needs preapproval by Keystone		Covered Services: Outpatient
Substance Abuse Treatment		Provided by Magellan Behavioral Health Services, Inc. Call 1-800-294-0800		Benefits
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
Vision Care & Eyewear		Annual Routine Eye Exam and Refractive Services Administered by Davis Vision. Call 1-888-393-2583 o locate a Davis Vision participating provider		Benefits
Well-Baby Visits		Provided by primary care physician		Primary & Preventive Care Primary & Preventive Care
X-Ray		Provided or referred by primary care physician		Covered Services: Outpatient