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Personal Choice Health
C1-F1-O1 C2-F1-O1 C3-F1-O1 C4-F3-O1
C1-F1-O2 C2-F1-O2 C3-F1-O2 C4-F3-O2
C1-F2-O1 C2-F2-O1 C3-F2-O1 C4-F4-O1
C1-F2-O2 C2-F2-O2 C3-F2-O2 C4-F4-O2
C1-F3-O1 C2-F3-O1 C3-F3-O1 C4-F5-O2
C1-F3-O2 C2-F3-O2 C3-F3-O2  
C1-F4-O1 C2-F4-O1 C3-F4-O1
C1-F4-O2 C2-F4-O2 C3-F4-O2
  C3-F5-O2

 

Personal Choice Deductible Health
D1-N1 D2-N1 D3-N1 D4-N1
D1-N2 D2-N2 D3-N2 D4-N2

 

Personal Choice RX
$0/$25/$50 $5/$20/$35 $10/$30/$50 $5/$40/$60
$0/$25/$50 No O.C. $5/$20/$35 No O.C. $10/$30/$50 No O.C. $250/$20/$40/$60
$5/$10/$25 $5/$30/$50 $15/$35/$50  
$5/$10/$25 No O.C. $5/$30/$50 No O.C. $15/$35/$50 No O.C.  
$5/$15/$25 $10/$20/$35 $20/$40/$60  
$5/$15/$25 No O.C. $10/$20/$35 No O.C. $20/$40/$60 No O.C.  

 

Keystone HMO Choice Health
C1-F1 C2-F1 C3-F1 C4-F3
C1-F2 C2-F2 C3-F2 C4-F4
C1-F3 C2-F3 C3-F3 C4-F5
C1-F4 C2-F4 C3-F4  
    C3-F5

 

Keystone POS Health
C1-F1-O1 C2-F1-O1 C3-F1-O1 C4-F3-O1
C1-F1-O2 C2-F1-O2 C3-F1-O2 C4-F3-O2
C1-F2-O1 C2-F2-O1 C3-F2-O1 C4-F4-O1
C1-F2-O2 C2-F2-O2 C3-F2-O2 C4-F4-O2
C1-F3-O1 C2-F3-O1 C3-F3-O1 C4-F5-O2
C1-F3-O2 C2-F3-O2 C3-F3-O2  
C1-F4-O1 C2-F4-O1 C3-F4-O1
C1-F4-O2 C2-F4-O2 C3-F4-O2
  C3-F5-O2

 

Keystone Direct POS Health
C1-F1-O1 C2-F1-O1 C3-F1-O1 C4-F3-O1
C1-F1-O2 C2-F1-O2 C3-F1-O2 C4-F3-O2
C1-F2-O1 C2-F2-O1 C3-F2-O1 C4-F4-O1
C1-F2-O2 C2-F2-O2 C3-F2-O2 C4-F4-O2
C1-F3-O1 C2-F3-O1 C3-F3-O1 C4-F5-O2
C1-F3-O2 C2-F3-O2 C3-F3-O2  
C1-F4-O1 C2-F4-O1 C3-F4-O1
C1-F4-O2 C2-F4-O2 C3-F4-O2
  C3-F5-O2

 

Keystone HMO Deductible Health
D1-N1 D2-N1 D3-N1 D4-N1
D1-N2 D2-N2 D3-N2 D4-N2

 

Keystone Direct POS Deductible Health
D1-N1 D2-N1 D3-N1 D4-N1
D1-N2 D2-N2 D3-N2 D4-N2

 

Keystone RX
$0/$25/$50 $5/$20/$35 $10/$30/$50 $5/$40/$60
$0/$25/$50 No O.C. $5/$20/$35 No O.C. $10/$30/$50 No O.C. $250/$20/$40/$60
$5/$10/$25 $5/$30/$50 $15/$35/$50  
$5/$10/$25 No O.C. $5/$30/$50 No O.C. $15/$35/$50 No O.C.  
$5/$15/$25 $10/$20/$35 $20/$40/$60  
$5/$15/$25 No O.C. $10/$20/$35 No O.C. $20/$40/$60 No O.C.  

 

Keystone Basic Dental and Vision
Basic Dental      
$100 Biennial Vision      
$35 Biennial Vision      

 

Health Savings Account
HD1-HC1 HD2-HC1 HD3-HC1 HD4-HC1
HD1-HC1 with RX HD2-HC1 with RX HD3-HC1 with RX HD4-HC1 with RX
HD1-HC2 HD2-HC2 HD3-HC2 HD4-HC2
HD1-HC2 with RX HD2-HC2 with RX HD3-HC2 with RX HD4-HC2 with RX

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