Flex Co-pay Series Plans
Keystone HMO
With the Keystone HMO plan each person in your family elects a Primary Care Physician (PCP) from the network to access care. Annual routine gynecologist exams do not require referrals. There are no out of network benefits. You are covered for Specialist Care, Hospitalizations, Maternity Care and an extensive array of Preventive Health Services.
Keystone Point of Service
Keystone Point of Service (KPOS) is an HMO plan that allows you to either elect care through a primary care physician or seek care directly from any provider - in our out of the network. Seeking care without a referral or from an out of network provider increases your out-of-pocket costs as deductible and coinsurance apply. Having care provided or referred by your PCP ensures your highest level of coverage.
Keystone Direct POS
Keystone Direct POS is similar to the KPOS plan in that members must choose a primary care physician, but have the ability to go to certain specialists without having to get referrals. Referrals are only required for spinal manipulation, laboratory, X-ray, physical/occupational therapy and podiatry.
Personal Choice
Choose your own doctors and hospitals without the necessity of a primary care physician or referrals. Maximum coverage is available by accessing preferred providers within the Personal Choice network. If you receive services from out-of-network providers, you will have higher out-of-pocket costs due to deductibles and co-insurance.
Mix and match the following options to get the plan that works right for you...
Physician Visit Copays
- $10 Primary - $20 Specialist
- $15 Primary - $30 Specialist
- $20 Primary - $40 Specialist
- $30 Primary - $50 Specialist*
*NOTE: This plan may only be paired with the $150 per day, $250 per day, and $400 per day Inpatient Hospital and Facility Copay options.
Inpatient Hospital and other Facility Care Copays
- $0 Inpatient Hospital - $0 Outpatient Surgery
- $100 per day ($500 Maximum per admission) Inpatient Hospital Copay - $50 Outpatient Surgery Copay
- $150 per day ($750 Maximum per admission) Inpatient Hospital Copay - $75 Outpatient Surgery Copay
- $250 per day ($1,250 Maximum per admission) Inpatient Hospital Copay - $125 Outpatient Surgery Copay
- $400 per day ($2,000 Maximum per admission) Inpatient Hospital Copay - $200 Outpatient Surgery Copay*
*NOTE: This facility option may only be paired with the $20/40 or $30/50 physician visit copay options above and the $1,500/$4,500 Annual Deductible options for out of network. (There is no out of network benefit on the HMO.)
Out of Network Benefits
- $500 Single/$1,500 Family Annual Deductible - 70%/30% Coinsurance to $3,000 Single/$9,000 Family - $1,000,000 Lifetime Maximum
- $1,500 Single/$4,500 Family Annual Deductible - 50%/50% Coinsurance to $10,000 Single/$30,000 Family - $500,000 Lifetime Maximum
Prescription Drug Co-pays
All prescription drug options will be from the Select Drug Program. The Select Drug Program uses a prescription drug formulary and provides coverage based on a three tier copayment incentive. Members pay less when using formulary medications, but have access to covered non-formulary medications with a higher copayment.
- $10 Generic Formulary - $20 Brand Name Formulary - $35 Non-Formulary
- $0 Generic Formulary - $25 Brand Name Formulary - $50 Non-Formulary
- $5 Generic Formulary - $40 Brand Name Formulary - $60 Non-Formulary
- $15 Generic Formulary - $35 Brand Name Formulary - $50 Non-Formulary
- $20 Generic Formulary - $40 Brand Name Formulary - $60 Non-Formulary
- $250 Deductible - $20 Generic Formulary - $40 Brand Name Formulary - $60 Non-Formulary
A Formulary list of drugs is available at www.ibx.com.
Please contact us for more information. For pricing, please complete a Rate Request Form.