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"Bold" print
identifies plan changes effective 1/1/2003
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Plan
Name
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Keystone
Health Plan Central, Inc.
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BlueCard
PPO In-Network
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BlueCard
PPO Out-of-Network
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Web Site
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www.khpc.com
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www.bluecares.com
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www.bluecares.com
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Member
Service Number
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1-800-622-2843
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1-800-810-BLUE
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1-800-810-BLUE
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Individual
Lifetime Maximum Benefits
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None
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$1 Million
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$500,000
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Annual
Deductible
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Individual
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None
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None
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$200
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Family
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None
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None
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$400
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Coinsurance
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None
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None
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25%
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Annual
Out-of-Pocket Maximum
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Individual
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None
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None
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$2,000
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Family
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None
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None
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$4,000
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Inpatient
Hospital
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100%
covered
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100% covered |
75%
after deductible; 90 days per calendar year |
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Physician
Services: PCP Office Visit
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$15
copay
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$10 copay
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75%
after deductible
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Emergency
Care: In-area Hospital
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$25
copay (waived if admitted)
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100% after $25 copay waived if admitted |
100%
after $25 copay - waived if admitted |
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Outpatient
X-Ray and Lab
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100%
covered
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100% covered |
75%
after deductible |
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Durable
Medical Equipment
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100%
covered
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100% with precertification
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75%
after deductible
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Retail
Prescription Coverage
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Generic
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$10
copay for a 30-day supply; $30 copay for 90-days
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15%
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15%
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Brand Name
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$20
copay for a 30-day supply (if generic is unavailable);
$20
copay plus cost difference
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25% if generic unavailable;30% if generic
available and medically necessary |
25%
if generic unavailable; 30% if generic available and medically
necessary |
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Mail-Order
Prescription Coverage
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Generic
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$20
copay for 90-day supply |
10% generic; 20% brand if generic unavailable; 25% if generic available
and medically necessary
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10% generic; 20% brand if generic unavailable; 25% if generic
available and medically necessary
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Brand Name
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$40
copay for a 90-day supply of Preferred Brand Names;
$40
copay for 90-day supply of Non-Preferred Brand Names plus cost
difference between Generic and Brand
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See Above
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See Above
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Diabetic
Benefits
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Insulin
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Covered
Under Pharmacy Benefit
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Covered Under Pharmacy Benefit |
Covered
Under Pharmacy Benefit |
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Chem. Strips/Lancets
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Covered
Under Pharmacy Benefit
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Covered Under Pharmacy Benefit
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Covered
Under Pharmacy Benefit
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Home Health Care
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100%
for up to 100 visits per calendar year
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100% for 100 visits per calendar year
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75%
after deductible; 100 visits per calendar year
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Mental
Health
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Inpatient
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100%
covered for up to 30 days per calendar year
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100% up to 30 days per calendar year
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75%
up to 10 days per calendar year
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Outpatient
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$25/
visit for up to 60 visits per calendar year. If not pre-approved as a
serious mental illneaa limited to 20 visits per calendar year.
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$10 copay up to 20 visits per calendar
year
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75%
up to 20 visits per calendar year
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Substance Abuse
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Inpatient
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100%
covered for up to 30 days per calendar year ; detox limited to 7 days;
90 days lifetime maximum
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100%; 28 days + 5 detox; 2 courses of
treatment per lifetime
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75%; 28 days + 5 detox/ 2 course of
treatment per lifetime
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Outpatient
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100%
covered, 60 full sessions visits per calendar year, lifetime max. of
120 days
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100%; 28 days + 5 detox;2 courses of
treatment per lifetime
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75% - 30 visits; 7 detox - two course of
treatment per lifetime
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Vision
Care
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Routine Eye Exam |
Not
Covered
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Not Covered
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Not Covered
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Eyeglasses and Contact Lenses
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Not Covered
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Not Covered
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Not Covered
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Hearing
Care |
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Exam |
$10
copay for one exam every 36 months
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Covered through National Ear Care Plan
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Nor
Covered
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Hearing Aids |
up
to $800 per ear every 36 months
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Covered through National Ear Care Plan
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Not Covered
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Dental
Care |
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Basic Services |
Not Covered
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Not Covered
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Not Covered
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Major Services |
Not Covered
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Not Covered
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Not Covered
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Preventive Services |
Not Covered
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Not Covered
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$30
copay
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Wellness
Benefits |
Yes
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$10 copay
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Not Covered
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*Footnote |
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Represented Railroad employees may have
slightly different RX copays
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