All PDFs
Flex POS Copay Options
Flex POS C1-F1-O1
Flex POS C1-F1-O2
Flex POS C1-F2-O1
Flex POS C1-F2-O2
Flex POS C1-F3-O1
Flex POS C1-F3-O2
Flex POS C1-F4-O1
Flex POS C1-F4-O2
Flex POS C2-F1-O1
Flex POS C2-F1-O2
Flex POS C2-F2-O1
Flex POS C2-F2-O2
Flex POS C2-F3-O1
Flex POS C2-F3-O2
Flex POS C2-F4-O1
Flex POS C2-F4-O2
Flex POS C3-F1-O1
Flex POS C3-F1-O2
Flex POS C3-F2-O1
Flex POS C3-F2-O2
Flex POS C3-F3-O1
Flex POS C3-F3-O2
Flex POS C3-F4-O1
Flex POS C3-F4-O2
Flex POS C3-F5-O2
Flex POS C4-F3-O1
Flex POS C4-F3-O2
Flex POS C4-F4-O1
Flex POS C4-F4-O2
Flex POS C4-F5-O2
Flex POS Direct Copay Options
Flex Direct POS C1-F1-01
Flex Direct POS C1-F1-02
Flex Direct POS C1-F2-01
Flex Direct POS C1-F2-02
Flex Direct POS C1-F3-01
Flex Direct POS C1-F3-02
Flex Direct POS C1-F4-01
Flex Direct POS C1-F4-02
Flex Direct POS C2-F1-01
Flex Direct POS C2-F1-02
Flex Direct POS C2-F2-01
Flex Direct POS C2-F2-02
Flex Direct POS C2-F3-01
Flex Direct POS C2-F3-02
Flex Direct POS C2-F4-01
Flex Direct POS C2-F4-02
Flex Direct POS C3-F1-01
Flex Direct POS C3-F1-02
Flex Direct POS C3-F2-01
Flex Direct POS C3-F2-02
Flex Direct POS C3-F3-01
Flex Direct POS C3-F3-02
Flex Direct POS C3-F4-01
Flex Direct POS C3-F4-02
Flex Direct POS C3-F5-O2
Flex Direct POS C4-F3-O1
Flex Direct POS C4-F3-O2
Flex Direct POS C4-F4-O1
Flex Direct POS C4-F4-O2
Flex Direct POS C4-F5-O2
Flex Deductible POS Direct Options
Keystone Direct POS D1-N1
Keystone Direct POS D1-N2
Keystone Direct POS D2-N1
Keystone Direct POS D2-N2
Keystone Direct POS D3-N1
Keystone Direct POS D3-N2
Keystone Direct POS D4-N1
Keystone Direct POS 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 2B
Keystone 5B
Keystone 5C
Keystone 10B
Keystone 10C
Keystone 15C
Keystone 15S
Keystone 105 D
Keystone 505 F
Keystone 510 F
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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