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 allowance*** | 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. year*) |
70% | 50% |
| Spinal Manipulations and Speech Therapy (20 visits each per cal. year*) |
70% | 50% |
| Cardiac and Pulmonary Rehabilitation (36 sessions each per cal. year*) |
70% | 50% |
| X-Ray/Radiology/Diagnostics** | 70% | 50% |
| Injectable Medications** | 70% | 50% |
| Lab/Pathology | 70% | 50% |
| Facility/Ancillary | ||
| Hospital Inpatient** (70 days out-of-network/self-referred) |
70% | 50% |
| Outpatient Surgery** | 70% | 50% |
| Skilled Nursing Facility** (PPO: 120 days per cal. year*; 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 Nursing** (360 hours per cal. year*) |
70% | 50% |
| Prosthetics and Durable Medical Equipment (DME)** (DME $2,500 maximum per cal. year) |
50% | 50% |
Coinsurance is based upon Plan allowance and reflects amount paid by the Plan.
* For Personal Choice, combined in/out-of-network maximum.
** Pre-authorization required for certain services.
*** Prosthetics and DME are covered at a 50% coinsurance level.