All PDFs
Flex HMO Copay Options
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
Flex HMO C4-F3
Flex HMO C4-F4
Flex HMO C4-F5
Flex Deductible HMO Options
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 Prescription (Rx) Benefit Summaries
HMO/POS Select $15/$35/$50 with oral contraceptives (Option 2)
HMO/POS Select $20/$40/$60 with oral contraceptives (Option 3)
Keystone Dental/Vision Benefit Summaries
Basic Dental Program
$35 Vision Biennial Program
$50 Vision Biennial Program
$75 Vision Biennial Program
$100 Vision Biennial Program
$125 Vision Biennial Program
$200 Vision Biennial Program
$250 Vision Biennial Program
$35 Corrective Eyewear Biennial Benefit
$100 Corrective Eyewear Biennial Benefit
Previously Grandfathered Plans:
Keystone 2
Keystone 5
Keystone 10
Keystone 15
Keystone Select
Keystone Select II
Keystone 105
Keystone 505
Keystone 510
Keystone 515
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
HMO/POS Select $5/$10/$25 with oral contraceptives
HMO/POS Select $5/$15/$25 with oral contraceptives
HMO/POS Select $5/$20/$35 with oral contraceptives
HMO/POS Select $10/$30/$50 with oral contraceptives
HMO/POS
Select $5/$30/$50 with oral contraceptives
HMO/POS
Select $0/$25/$50 with oral contraceptives
HMO/POS Select $5/$40/$60 with oral contraceptives
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