Select copay option for network doctor's office visits, therapies and diagnostic care.
Office/Outpatient Care |
C1 |
C2 |
C3 |
 C4* |
|---|---|---|---|---|
| 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. year**) | $20 | $30 | $40 | $50 |
| Spinal Manipulations and Speech Therapy | ||||
| (20 visits each per cal. year**) | $20 | $30 | $40 | $50 |
| Cardiac and Pulmonary Rehabilitation | ||||
| (36 sessions each per cal year**) | $20 | $30 | $40 | $50 |
| X-Ray/Radiology/Diagnostics | ||||
| Routine Radiology | $20 | $30 | $40 | $50 |
| MRI/MRA, CT Scans, PET Scans*** | $40 | $60 | $80 | $100 |
| Injectable Medications | ||||
| Standard Injectables | $0 | $0 | $0 | $0 |
| Biotech/Specialty Injectables*** | $50 | $75 | $100 | $125 |
| Lab/Pathology | ||||
| Copayment: | $0 | $0 | $0 | $0 |
* C4 can only be paired with F3, F4, or F5.
** For Personal Choice, combined in/out-of-network maximum.
*** Pre-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.