Benefits

Keystone - HealthPlan Central - HMO

Choose a Primary Care Physician (PCP) from Keystone’s extensive Central Pennsylvania provider network who will coordinate all the medical services you need. This will be done by either treating you directly or making referrals to an appropriate specialis t or hospital. There are no out-of network benefits.

Visit the Keystone HMO Web site

PROFESSIONAL SERVICES
Service	Co-payment
Primary Care Physician Office Visits	$5 copay
Specialist Consultations	$5 copay
Surgeon's Fees	100%
In-Hospital Physician Visits/Consultations	100%

PREVENTIVE HEALTH SERVICES
Service	Co-payment
Periodic Physical Exam	$5 copay
Routine Immunizations	100%
Gynecological Services (no referral)	$5 copay
Well-Baby/Well-Child Care	$5 copay
Annual Mammograms (no referral) Age 40+	100%

MATERNITY
Service	Co-payment
Obstetrical Care (pre/post natal/delivery)	$5 copay first visit
Newborn Care (physician/hospital services)	100%

HOSPITAL SERVICES
Service	Co-payment
Unlimited Days (semi-private)	100%
Intensive Care, Operating Room, Imaging, Lab Tests, Anesthesia, Drugs, Chemotherapy	100%

WORLD-WIDE EMERGENCY CARE
Service	Co-payment
Emergency Room Services	$50 copay (waived if admitted)
Emergency Ambulance Services	100%
Urgent Medical Care-Outside Service Area	$50 copay (waived if admitted)
Urgent Medical Care-Inside Service Area	$5 office copay or $15 after-hours copay

ADDITIONAL SERVICES
Service	Co-payment
Outpatient Laboratory/Imaging Services	100%
Allergy Testing/Treatment (including serum)	100%
Outpatient/Inpatient Short-Term Rehab Therapies -Physical, Occupational, Speech, Cardiac, Respiratory, Urinary Incontinence, Orthoptic (60 per condition per calendar year)	100%
Home Health Services (100 visits per calendar year)	100%
Outpatient Chemotherapy	100%
Hemodialysis	100%
Skilled Nursing Facility	100%
Outpatient Ambulatory Surgery (office, facility)	100%
Hospice Care (max $7,500 benefit per member)	100%
Infertility Services (max $2,500 per member)	50%

MENTAL HEALTH SERVICES
Service	Co-payment
Serious Mental Illness Up to 30 Inpatient days per calendar year (unused calendar year days may be exchanged on a 1 for 2 basis to secure add'l O/P visits) Up to 60 Outpatient visits per calendar year -Individual Session -Group Session	100% $25 copay $5 copay
Other Than Serious Mental Illness Up to 30 Inpatient days per calendar year Up to 20 Outpatient visits per calendar year -Individual Session -Group Session	100% $25 copay $5

SUBSTANCE ABUSE/ADDICTIONS
Service	Co-payment
Inpatient Detoxification (Detox limited to 7 days per admission; 4 admissions per lifetime)	100%
Inpatient Rehabilitation Rehab services limited to 30 days per year; lifetime limit of 90 days	100%
Outpatient Services 60 full-session visits per calendar year; lifetime limit of 120 visits 1st Course of Treatment Additional Courses -Full Session -Partial Session	$0 copay $25 copay $15 copay

PRESCRIPTION DRUGS
Service	Co-payment
Prescription Drugs (Contraceptives included) Per 30-day supply, Generic Program* & Drug Formulary	$10 generic $25 preferred brand $40 non-preferred brand
Mail-Order "Maintenance" Drugs (Contraceptives included), up to a 90-day supply, Generic Program*	$20 generic $50 preferred brand $80 non-preferred brand
*If a generic equivalent is unavailable, the member pays the brand-name drug copay. If a generic equivalent is available and a brand-name drug is either prescribed by a doctor or selected by the member, the member pays the brand-name drug copay and the cost difference between the generic equivalent and the brand-name drug.

KEYSTONE PAYS FOR COVERED MEDICALLY NECESSARY HEALTH CARE SERVICES ONLY IF APPROVED BY YOUR PRIMARY CARE PHYSICIAN

NOTE: THIS IS INTENDED TO ONLY BE A SUMMARY OF BENEFITS AND NOT AN ALL INCLUSIVE SUBSCRIBER AGREEMENT.