Keystone HMO ProactiveCommercial tiered network product
Keystone HMO Proactive — our lower-cost, tiered provider network product — is available to individuals and small groups. Keystone HMO Proactive has benefit designs with different member cost-sharing by tier and offers members lower out-of-pocket costs (e.g., copayment) for most services when they select or are referred to a provider in the Preferred benefit tier.
Our HMO network providers have been categorized into one of three benefit tiers for Keystone HMO Proactive:
- Tier 1 — Preferred: Members pay the lowest cost-sharing for most services.
- Tier 2 — Enhanced: Members pay a higher cost-sharing for most services compared to Tier 1 — Preferred.
- Tier 3 — Standard: Members pay the highest cost-sharing for most services.
Benefit tier placement
- Primary care physicians (PCP): Criteria include relative cost (i.e., contracted fee schedule), minimum quality standards, if applicable, and the tier of the facilities in which a PCP typically refers Independence patients for hospital and outpatient surgical services.
- Specialists: Criteria include relative cost (i.e., contracted fee schedule) and the tier of the facilities in which a specialist typically refers Independence patients for hospital and outpatient surgical services.
- Hospitals: Criteria include cost and minimum quality standards
- Ancillary providers: Benefit tier placement is based on relative cost (i.e., contracted fee schedule) as compared to other network providers in an ancillary provider’s specialty
Frequently asked questions
Keystone HMO Proactive members pay the lowest cost-sharing for most services when they use a Tier 1 — Preferred provider.
View our list of Keystone HMO network hospitals by state and benefit tier.
Services that have the same cost-sharing across all tiers include, but are not limited to, the following:
- preventive care
- urgent care
- physical, occupational, and speech therapy
- mental health
Learn more about Keystone HMO Proactive plans.
The pharmacy network for Keystone HMO Proactive plans is a smaller version of our full FutureScripts® pharmacy network. Specifically, the Preferred Pharmacy Network excludes Walgreens and Rite Aid. If a member elects to get a prescription filled at Walgreens or Rite Aid, it will be considered an out-of-network claim and the member will be responsible for the total cost of the prescription drug(s) at the pharmacy. Some members can submit a paper claim for partial reimbursement.
With this preferred network, members will continue to have access to more than 50,000 pharmacies, such as CVS, Wal-Mart, and Target, in addition to independent pharmacies.
View the Minimum Quality Criteria for Hospitals and PCPs
¹Benefit tier placements for hospital-based outpatient radiology centers and labs follow their affiliated hospital. These hospital-based outpatient facilities were not evaluated separately from their affiliated acute care hospital.
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