All PDFs
Flex HMO Copay Options
(may be paired with any Keystone Rx option)
Flex HMO C1-F1
Flex HMO C1-F2
Flex HMO C1-F3
Flex HMO C1-F4
Flex HMO C2-F1
Flex HMO C2-F2
Flex HMO C2-F3
Flex HMO C2-F4
Flex HMO C3-F1
Flex HMO C3-F2
Flex HMO C3-F3
Flex HMO C3-F4
Flex HMO C3-F5 (effective 7/1/2007)
Flex HMO C4-F3 (effective 7/1/2007)
Flex HMO C4-F4 (effective 7/1/2007)
Flex HMO C4-F5 (effective 7/1/2007)
Flex Deductible HMO Options
(may be paired with Keystone Rx Options 5, 6, 7, 8 or 9 only)
Flex HMO D1-N1
Flex HMO D1-N2
Flex HMO D2-N1
Flex HMO D2-N2
Flex HMO D3-N1
Flex HMO D3-N2
Flex HMO D4-N1
Flex HMO D4-N2
Keystone Health Plan East Pre- Authorization Information
Keystone Health Plan East Pre-Authorization
KHPE Flex Pre-Authorization
Keystone Prescription (Rx) Benefit Summaries
Select Drug Formulary Guide effective 7/1/07
Select Drug Program Key Discussion Points
Select Drug Program Q & A
Select Drug Program Q & A for Injectable Coverage
Biotech/Specialty Injectables List
Procedures That Support Safe Prescribing
Select Drug Formulary Guide
HMO/POS Select $5/$10/$25 with oral contraceptives (Option 1)
HMO/POS Select $5/$15/$25 with oral contraceptives (Option 2)
HMO/POS Select $5/$20/$35 with oral contraceptives (Option 3)
HMO/POS Select $10/$30/$50 with oral contraceptives (Option 4)
HMO/POS Select $10/$20/$35 with oral contraceptives (Option 5)
HMO/POS Select $15/$35/$50 with oral contraceptives (Option 6)
HMO/POS Select $20/$40/$60 with oral contraceptives (Option 7)
HMO/POS
Select $0/$25/$50 with oral contraceptives (Option 8)
HMO/POS
Select $5/$30/$50 with oral contraceptives (Option 9)
Keystone Dental/Vision Benefit Summaries
Keystone Basic Dental Program
$35 Vision Bi-Annual Program
$50 Vision Bi-Annual Program
$75 Vision Bi-Annual Program
$100 Vision Bi-Annual Program
$125 Vision Bi-Annual Program
$200 Vision Bi-Annual Program
$250 Vision Bi-Annual Program
$35 Corrective Eyewear Bi-Annual Benefit (Keystone Rider)
$100 Corrective Eyewear Bi-Annual Benefit (Keystone Rider)
The following Keystone plans are available for Renewals only:
Keystone Health Plan East 2 Benefit Summary
Keystone Health Plan East 5 Benefit Summary
Keystone Health Plan East 10 Benefit Summary
Keystone Health Plan East 15 Benefit Summary
Keystone Health Plan East Select Benefit Summary
Keystone Health Plan East Select II Benefit Summary
Keystone Health Plan East 105 Benefit Summary
Keystone Health Plan East 505 Benefit Summary
Keystone Health Plan East 510 Benefit Summary
Keystone Health Plan East 515 Benefit Summary
The following Keystone Rx plans are available for Renewals only:
HMO/POS Standard Rx $5/$20 with oral contraceptives
HMO/POS Standard Rx $6/$10 with oral contraceptives
HMO/POS Standard Rx $10/$15 with oral contraceptives
HMO/POS Standard Rx $10/$20 with oral contraceptives
HMO/POS Standard Rx 50% with oral contraceptives
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