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Student Health Insurance Plans In Pennsylvania – Compare Options

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Low cost student health insurance coverage in Pennsylvania is very easy to purchase.  We help you find quality plans (both on and off the Marketplace) through all of the major insurers such as Aetna, UnitedHealthCare, UPMC, Coventry Highmark BCBS, Capital BC, Keystone, Independence Blue Cross, Geisinger, and many other providers.  Sometimes, University policies don’t provide the specific benefits that you want, or feature the low rates that you need to fit within your budget.

We show you flexible policies that keep rates affordable, but also give you top-notch coverage that you can use almost everywhere. All policy options are Affordable Care Act-compliant and contain all required essential health benefits (required by Obamacare legislation) including maternity, mental health, prescriptions, ER, office visits, hospital and many others. You can accept a federal subsidy (if available), or choose a private policy that receives no federal aid.

Provider Networks are often larger when you purchase your own policy. A wide variety of specialists are generally available for specific treatment. If traveling outside of the Keystone State, major medical, preventative, and routine medical expenses can be covered. Emergency treatment away from home is also covered, including the ER and Urgent Care facilities. Note: Several of the previously-mentioned carriers offer small and large group coverage, but not private individual or family plans.

Best Available Rates

Any Pennsylvania student rates you view on this website have our “best price” approval. You can apply for these plans either online or by going direct. If you’re a recent graduate from a Pa school, you can also purchase inexpensive short-term coverage, or if you are away from home, there are many additional options. If you are taking part-time hours, you still are eligible. Since most policies are generic, adults taking part-time or full-time classes can also purchase these types of contracts.

If you are planning on studying abroad, there are specialty plans that will be much better-suited for the type of international needs you will have. These policies will allow you to receive treatment (including emergencies) in the countries you are visiting, including paying medical bills you incur back in the US until you enroll in a conventional plan.  Evacuation expenses can also be covered. Once you return to the US, however, more traditional and conventional plans should be chosen.

Which Schools

Most Pennsylvania colleges and universities (Penn State, Pitt, Temple, Duquesne, Penn, LaSalle, Slippery Rock, Villanova, Lehigh etc…) require their students to have comprehensive health insurance, either through a parent’s plan, their own university policy, or an individual plan. If you are not eligible for affordable coverage under a parent’s private or employer-sponsored benefit, then buying your own policy from one of the major companies should be considered. Regardless if you qualify for a financial subsidy, prices will be inexpensive, and pre-existing conditions will be covered (assuming you have previously met Open Enrollment guidelines).

Or, if your school plan is too expensive, you may be able to save money when you buy a private policy. If you are attending a college in another state, it’s important to understand that some plans may limit where you receive treatment (such as an HMO). A PPO (Preferred Provider Organization) is much more likely to allow you to seek treatment away from campus. Routine medical situations can often  be treated at an on-campus facility. Several student health insurance guides are available along with our customized reviews of specific schools.

Best Student Health Insurance Prices In Pa

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Having a large choice of Network medical facilities, physicians and specialists is extremely important, especially if you attend an out-of-state school. Student health plans purchased through a university could limit the type of care you receive and where you can go to receive the treatment. This may become very evident  if chronic conditions require regular specialist visits. Even if the condition is temporary, the cost could be overwhelming without the most appropriate policy.

We help you find the options that provide the coverage you are required to have. Whether you attend a specific school, or you’re a undergraduate or graduate student, we’re experienced  in making the selection and application process easy. Interpreting the requirements that your school requires can be very confusing and tedious. We compare these types of requirements each day, so we can easily and quickly determine your best course of action.

Provider List

Your own individual plan will include off-site doctors, hospitals and other specialists, if needed. Even if Network specialized medical care is located hundreds of miles from school, you will have access to that treatment. Almost all of the large Pennsylvania health insurers feature large Networks including the best specialists in the state. When we review your options, we’ll make certain that there are a wide selection of providers.

Most companies allow you to be billed monthly, instead of paying an entire semester of premiums at once.  And you can keep coverage after you graduate and also if you never finish. Since you own the plan, you determine if/when you want to renew it. As a result of annual Open Enrollments, you can also freely change plans and companies every year, regardless of any medical conditions you may have.

Student Health Insurance Rates In Pa

For example, a 19-year old in the Philadelphia and Pittsburgh areas (assuming income of $20,000 per year and applied federal subsidy) can buy comprehensive coverage for as little as $26 per month (see below).


Montgomery, Philadelphia, Delaware, Bucks and Chester Counties

$26 – Independence Blue Cross Bronze Basic – $40 pcp office visit copay after deductible is met.

$41 – Independence Blue Cross Personal Choice PPO Bronze Reserve – 0% coinsurance.

$52 – Independence Blue Cross Personal Choice PPO Bronze – $50 pcp office visit copay.

$60 – Independence Blue Cross Keystone HMO Silver Proactive – $10 and $20 office visit copays and $0 deductible.

$82 – Independence Blue Cross Keystone HMO Silver – $5 and $15 office visit copays and $1,000 deductible.


Allegheny, Westmoreland, Washington, and Beaver Counties


$68 – UPMC Advantage Bronze $6,950/$35 – $35 Copay on pcp visits.

$80 – UPMC Advantage Silver $3,250/$10 – $5 and $25 office visit copays and $1,000 deductible.

$82 – UPMC Advantage Silver $1,750/$30 – $15 and $30 office visit copays and $500 deductible.

$83 – UPMC Advantage Silver HSA $2,600/20% – Not the best option for students.

$83 – UPMC Advantage Silver $0/$50 – $0 deductible with $25 and $60 copays.


Dauphin, Lebanon, Cumberland, and Perry Counties


$55 – Geisinger Marketplace HMO 30/60/3500 – $15 and $25 office visit copays. $600 deductible with maximum out-of-pocket expenses of $2,350.

$82 – Capital BlueCross Silver PPO 4500/0/10 – $5 and $10 office visit copays. $1,100 deductible with maximum out-of-pocket expenses of $2,350.

$95 – Highmark Alliance Flex Blue PPO 2300 – $25 and $40 office visit copays. $700 deductible with maximum out-of-pocket expenses of $1,400.

$110 – Geisinger Marketplace HMO 20/40/6000 – $20 and $40 office visit copays. $3,000 deductible with maximum out-of-pocket expenses of $4,000. $15 generic drug copay.

$126 – Capital BlueCross Silver PPO 4500/0/10 – $20 and $50 office visit copays. $1,000 deductible with maximum out-of-pocket expenses of $7,150.


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If you’re working part-time, there is a possibility that you may be eligible for group benefits. However, typically, the most economical employer-based coverage is reserved for full-time employees.  Thus, your group rate may be quite high compared to other private options. There also may be a specific employee  “open enrollment” period, and if you miss the deadline, you’ll have to wait another year.

We prefer private options because you can also customize a policy to match the benefits that you feel are the most important. Thus,  if you need maternity or tuition protection with low out-of-pocket costs for a medical condition withdraw, there are specific carriers that will specialize in those needs, by reducing out-of-pocket costs. There are many occasions, when schooling may be interrupted because of a sickness or illness. That’s when you may need your own coverage the most.


2017/2018 Pa University Student Health Plan Information And Rates For 11 Largest Schools


University Of Pittsburgh – The University of Pittsburgh Medical Center Health Plan is available to full-time undergraduate students and all graduate students. Coverage is underwritten by UPMC. The monthly rate for a single student is $188.62, and $526.07 for a student and one child. The rates for a student and spouse is $1,244.63 and $1,582.07 for an entire family. Dental and vision benefits are also available ($15.32 and $6.78 monthly rates respectively for a single student).

Plan deductibles are $250 per person, and $500 per family. Maximum out-of-pocket expenses are $4,200 per person and $8,400 per family. Office visit copays (pcp and specialist) are $30 and $40. The Urgent Care and ER copays are $40 and $75. Prescription drug copays are $15 for generic and $35 for preferred brands. Non-preferred brand and specialty medication copays are $70.


Penn State University – The Penn State  plan (SHIP) is provided by UnitedHealthcare Student Resources. Coverage is offered to undergraduates, graduate, law, and professional students, graduate assistants and fellows, international students, and Hershey College of Medicine students. Aetna previously provided benefits. International students must have existing medical coverage to continue enrollment in good standing. September 5th is the last day to enroll for Fall semester benefits. May 21st is the deadline for summer session coverage.


University Of Pennsylvania – “PSIP” is offered and Aetna is again the underwriter for undergraduate students. Graduate and professional program students have their costs included in their attendance budget when estimating financial aid. The annual rate for single students is $3,348, $3,348 for a spouse, and $3,348 for a child. The annual rate for two or more children is $6,696.

Utilizing “Preferred Care” facilities provides lower out-of-pocket costs. The annual deductible is $300 per person, with  $900 maximum out-of-pocket expenses. Office visit and Urgent Care copays are $30. The ER copay is $100.  The diagnostic test and x-ray copay is $35, while the imaging copay is $50. Prescription drugs are covered with the following copays: $20 – generic $40-preferred brand, non-preferred brand – $40, and specialty – $40.

Dental benefits are also offered through the Penn Dental Family Practice. Covered services include implants, oral surgery, cosmetic surgery, general and pediatric dentistry, orthodontics, and teeth whitening. 35 physicians are available along with additional practitioners. A “Vital Savings Discount” program is also offered for basic dental needs. However, coverage is limited, and discounts will vary, depending upon the procedure. Also benefits are not recognized by the Penn Faculty Practice.


Indiana University Of Pennsylvania – IUP does not offer coverage, although there is a “service fee” that every student must pay. This charge covers the cost of the campus clinic for basic services (common colds, the flu, etc…).   Incoming freshman and transfer students must also provide proof of the following immunizations: Polio, Diphtheria, Mumps, Measles, Rubella, and Tetanus.

The Health Service Clinic is open during most business hours and can treat basic injuries and illnesses. Physicians and nurses are available to treat patients. Payment is not collected at the time of treatment, since billing statements are sent directly to the Bursar for direct pay. Prescribed medications can be picked up at local pharmacies. The facility is located at 901 Maple Street. Several  available services (and their charges) are: basic visit for illness or injury – $10, pregnancy testing – $15, STD tests – $25, annual physicals – $35, allergy injections – $5, crutches – $30, sutures – $5, use of nebulizer – $5, and air cast – $15.


Temple University – Undergraduate, graduate, law, pharmacy, dental, and international students are eligible to purchase coverage. The three available plans are Personal Choice PPO, Keystone Standard Point-Of-Service, and  Keystone Premium Point-Of-Service. Each of the three policies is underwritten by Independence Blue Cross, and complies with Affordable Care Act requirements. There are also no deductibles to meet although maximum out-of-pocket expenses apply. Each of the three plans has a maximum out-of-pocket maximum of $6,600 (per person) and $13,200 per family. Note: Routine and basic visits are covered by Student Health Services (part of the University Services fee).

The Personal Choice PPO plan has $20 and $40 office visit copays with a $70 copay for Urgent Care visits. Inpatient hospital visits are subject to a $150 copay per day (maximum five copays), and ER visits have a $100 copay. Routine diagnostic x-rays are subject to a $40 copay.  Most therapy services require a $40 copay.  There is no deductible and maximum out-of-pocket expenses are $6,600.

The POS Standard plan has $30 and $50 office visit copays with a $70 copay for Urgent Care visits. Inpatient hospital visits are subject to a $250 copay per day (maximum five copays), and ER visits have a $100 copay.  There is no deductible and maximum out-of-pocket expenses are $6,600. Therapy services are subject to a $50 copay.

The POS Premium plan has $15 and $30 office visit copays with a $70 copay for Urgent Care visits. Inpatient hospital visits are subject to a $100 copay per day (maximum five copays), and ER visits have a $100 copay. There is no deductible and maximum out-of-pocket expenses are $6,600. Therapy services are subject to a $30 copay.

The monthly single rates (full-time students) for the Personal Choice, Keystone Standard, and Keystone Premier are $256, $239, and $247 respectively. Prices for family coverage are quite high, like most college plans. They are $750, $709, and $736. To cover a student and one dependent, the monthly rates are $570, $533, and $553.

Cheap Pittsburgh Student Medical Coverage

The Duquesne University Student Health Plan Is Underwritten By Highmark

Duquesne – All full-time undergraduate, graduate, and international students are required to select the official student health plan, or provide proof that qualified coverage is in currently in effect.  Highmark BCBS underwrites the Duquesne plan by providing PPO Blue coverage. The cost is $1,895.84, which is billed in the fall and the spring ($972.92 and $922.92). The policy deductibles are $500 per person and $1,000 per family. The maximum out-of-pocket expenses are $4,500 and $9,000 respectively.

Retail clinic and pcp office visit copays are $25, while the specialist visit copay is $35. The Urgent Care copay is $50, while the ER copay is $125, with 80% coverage thereafter. Pediatric dental and vision routine visits are covered at 100%. Prescription drugs do not have a deductible to meet. The retail copays for a 31-day supply are $10 for generic, $35 for formulary brand, and $50 for non-formulary brand. the 90-day copay for maintenance drugs are $20, $70, and $100.


Carnegie-Mellon -Full-time students (Pittsburgh and Silicon Valley campuses) are required to have medical coverage that satisfies the school’s requirements. If other coverage meets the University requirements, a waiver can be granted. The healthcare plan is underwritten by Aetna, one of the nation’s largest carriers. The annual cost for a single student is $2,039. Adding a dependent increases the rate to $4,043. The annual family rate is $6,047. The annual individual dental and vision coverage rates are $214 and $82.44 respectively. Family rates are $538 and $224.64.

The annual deductible is $250 with  maximum out-of-pocket expenses of $5,000. The office visit and Urgent Care copays are $25, while the ER copay is $125. Diagnostic tests are subject to a $25 copay and imaging is subject to a $40 copay. Hospital room and board, and intensive care expenses, are covered with a $150 copay. 100% coverage of the negotiated price is provided after the copay has been paid. Therapy (radiation, inhalation, chemotherapy, kidney dialysis, and respiratory) is paid at 100% of the negotiated charge.

The generic and preferred brand drug copays are $15 and $35. The non-preferred brand and specialty drug copay is $65. A waiver (deductible and copay) is given for many female prescription drug contraceptives.


Drexel – All students are required to furnish proof of coverage by August 30th. A waiver is granted of a set of specific requirements are met. $2,500 is the maximum allowed deductible (exception for HSAs), and mental health and substance abuse benefits must be included. At least $500,000 of benefits must be provided by a carrier licensed and approved to conduct business in the US. And of course, pre-existing conditions must be covered.

Current coverage is underwritten by Aetna with the following annual rates: Student – $2,166. Student plus spouse or child – $4,292. Student plus two (or more) children – $6,418. Student plus spouse and child – $6,418. Student plus spouse plus two (or more) children – $8,544. Law students and college of medicine students pay slightly higher premiums.

The deductible is $100 (per person) with  maximum out-of-pocket expenses of $5,000. Office visit copays are $20, with an Urgent Care copay of $30. The copays for generic, preferred brand, and non-preferred brand drugs are $15, $30, and $45.


Villanova – Unless a waiver is granted, all students (domestic undergraduate, and international)  are required to maintain health insurance benefits. UnitedHealthcare offers coverage at the following non-renewable one-year annual rates: Single – $1,985 Spouse – $1,985. Each child – $1,985. Spouse plus two or more children – $5,955.

The in-network deductible is $200 ($600 out-of-network) with  maximum out-of-pocket expenses of $2,000 per person and $4,000 per family. Coinsurance is 90%. It closely resembles Marketplace Platinum-tier contracts. Prescription drug copays  for Tiers 1, 2, and 3, are $15, $30, and $45. Most benefits  are provided with the “preferred allowance.” Examples include room and board, intensive care, physician visits, diagnostic tests, x-rays, procedures, ambulance services, Urgent Care,  and medical emergency expenses.


Bloomsburg State – Similar to IUP, Bloomsburg does not offer a specific plan to its student body, but offers online links that provide basic information to help in the selection process. However, University fees cover basic  treatment from the Student Medical Center. Part-time physicians and registered nurses can be accessed by appointments (only). There is no limit on the number of times a student can visit. Annual physicals and pregnancy testing are offered for a small cost.


Kutztown State – Students are not offered a University-sponsored plan. However, if the health center fee has been paid, and the appropriate medical forms have been completed,  a campus ambulatory facility (Clinical Services) is provided. Although walk-in business is allowed, appointment are preferred.  Routine treatment is provided for several services, including routine physicals, allergy injections, immunizations, flu or cold, strep testing, vomiting and diarrhea.


West Chester University – Student healthcare coverage is longer offered. Previously, plans utilizing the Cigna PPO network were available. Student Health Services, located on the ground floor at Commonwealth Hall, can be utilized. The fee charged for a visit is $12 if the health services charge has been paid with tuition. Otherwise, the charge is $20. Many services are available, including basic health care, allergy shots, immunizations (Hepatitis B, HPV, influenza, measles, mumps, rubella, and tetanus), medications, disposal of needles, TB testing, prescribing oral contraceptives, STI testing, and GYN exams.


Impact Of Legislation

A student “Bill Of Rights” is available, which can be found by clicking on this link. This final ruling  is  part of  “The Affordable Care Act.” It’s very long and wordy, so we’ll quickly summarize it. Annual limits may not be less than $100,000 on essential health benefits. Also, the “MLR” (Medical Loss ratio) applies, although plans will be considered separately instead of state by state. Of course, the much longer version can be found through the link.

You may also remain on a parent’s policy until age 26, assuming certain residency and eligibility guidelines are met. This can result in lower premiums (sometimes) and identical benefits to other family members. A comprehensive Group plan will often feature low deductibles and copays. If a chronic illness is present, purchasing an upper-end Exchange plan may lower out-of-pocket costs, especially if non-generic specialty drugs are needed.


Your free quote only takes a few minutes (see top of page). It allows you to easily see the rates from the best companies. You can also call or email us. We’ll help you choose the best plan, and explain the easiest way to apply for coverage. If your school or University needs written confirmation, we will provide it.

Highmark BCBS Pa Health Savings Blue PPO HSA Plans

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Highmark Blue Cross Blue Shield provides comprehensive qualified high deductible plans in Western Pennsylvania. As “HSA-friendly” plans, the PPO 1700 and PPO Embedded 2700 can be used in conjunction with a Health Savings Account.  Health Savings Blue is a perfect Marketplace fit for the self employed, families or individuals that want quality coverage at a reasonable price. Both options are available with or without federal financial aid.

As a guaranteed-issue Exchange policy, applying for coverage only requires a simple five-minute application to be completed, and a face-to-face meeting is not necessary. Coverage is offered in the selected counties of Western Pa during Open Enrollment periods. However, you can also qualify for a Special Enrollment Period that may allow you to apply for a policy at any time throughout the year.

The Health Savings Blue PPO 1700 and Embedded 2700 plans are available in the following counties: Allegheny, Beaver, Bedford, Blair, Butler, Cambria, Erie, McKean, Somerset, Venanago, Washington, and Westmoreland.


How Does It Work?

An HSA is one of the best tools available to help pay for future medical, dental, and vision expenses, and get a tax deduction at the same time! Premiums are usually lower than a”comprehensive” plan, and you have more control over your treatment than ever before. If you change companies (For example, Highmark to UPMC, or Highmark to Aetna) you can continue with the same savings account, while only changing the HDHP (High Deductible Health Plan).

No funds are ever “lost” if you don’t use them in time, and a debit card helps manage how and when you pay for qualified expenses. Another big advantage is that you receive the tax deduction for your contributions, even if you have not yet spent the money on approved expenses. For example, if you have an extremely healthy year with no medical expenses, you can still benefit from tax savings. Deposits that are applied for the prior tax year can be made through April 15th (or later, if the 15th occurs on a weekend).

Get Highmark HSA Rates In Pennsylvania

Highmark HSA Plans Save Money

Once you reach age 65, your funds can continue to pay for Medigap plan coverage, or you can supplement your retirement income. You can also have your claims automatically paid electronically, or simply review the details before any money is dispersed. However, you can not tax-deduct premiums paid for the purchase of Medicare Supplement, Advantage, or Part D prescription drug plans.


What’s covered? other than the obvious (major medical, office visit and prescriptions), there are hundreds of treatments that are fully deductible. Some less-than-obvious and more obscure examples are: artificial teeth, birth control, breast pumps, guide dogs, hearing aids, lead-based paint paint removal, oxygen, sterilization, vasectomy and weight-loss assistance. A complete list can be found in this IRS publication on approved expenses.

These types of policies must conform to the Affordable Care Act guidelines, so the mandated “10 Essential Benefits” (EHBs) are included along with specific coverage that the State of Pennsylvania requires. For example, maternity and newborn expenses are always covered, although if non-preventative, a deductible may apply. However, it is expected that several changes and enhancements will be made when the Trump Administration plans are formally effective in 2018.

You may qualify for the Advanced Premium Tax Credit (APTC) that reduces the premium. However, for Silver-tier contracts, too large of a subsidy through cost-sharing, may reduce the deductible to the level that the contract becomes ineligible for HSA status. We can review those circumstances with you, to ensure that you are IRS-compliant.

Deductible And Preventive Expense Options

There are numerous deductible options. For example, if coverage is for just one person, you may select a deductible as low as $1,300. The minimum family deductible is $2,600. The maximum allowed out-of-pocket expenses are $6,550 and $13,100 respectively.

All preventive treatment is paid in full with no copays, deductibles, coinsurance or waiting periods. A full list of covered items is available through the Department of Health and Human Services or we can email you a complete listing. Most other treatment is provided at negotiated repricing, meaning that until the deductible is met, you receive a substantial discount in cost, courtesy of Highmark. The Highmark BCBS provider network must be used to secure the largest negotiated discounts.

The discounts may range from 5%-20% (office visits) to as much as 50%-85% (lab tests and other diagnostic expenses). For major surgeries or long hospital confinements, it is not uncommon to see tens of thousands of dollars “repriced” from the original bill. Often, treatment for a chronic condition that requires an overnight stay will also cost much less by utilizing carrier network savings. Prescriptions will also cost less, although the savings is not substantial for generic and preferred non-generic drugs.

What Counties Must I Live In To Purchase Coverage?

Highmark Blue Cross Blue Shield Pa Prices

Highmark BCBS Serves Pittsburgh, Allegheny County, And Western Pa.

Allegheny, Beaver, Bedford, Blair, Butler, Cambria, Erie, McKean, Somerset, Venanago, Washington, and Westmoreland (As previously noted).

NOTE: HSA plans in Pennsylvania (all parts) are offered by many other carriers, including UPMC, Aetna and UnitedHealthcare. Also, although these contracts are available in Delaware, (Coventry also offers plan in the state), we are focusing on the Pa options only.

Specific Details

Health Savings Blue PPO 1700 – Individual deductible is $1,700 with family deductible of $3,400. The single and family out-of-pocket maximums are $3,250 and $6,500. Coinsurance is 10%. Most HSAs feature 0%, 10%, 20%, 30%, 0r 50% coinsurance. Therapy and rehab services are covered along with occupational and speech therapy.  There is a 30-visit limit for rehabilitative services, and a 20-visit limit for chiropractor visits.

Pediatric vision and dental services are included. After deductible has been met, there are no out-of-pocket expenses for frames, lenses, exams, cleanings, and basic restorative services. Prescription drug coverage (mail and retail) is subject to 10% coinsurance after the deductible is met.


Health Savings Blue PPO Embedded 2700 – Individual deductible is $2,700 with family deductible of $5,400. The single and family out-of-pocket maximums are $6,500 and $13,000. Coinsurance is 20%.  Therapy and rehab services are covered along with occupational and speech therapy.  There is a 30-visit limit for rehabilitative services, and a 20-visit limit for chiropractor visits.

Pediatric vision and dental services are included. After deductible has been met, there are no out-of-pocket expenses for frames, lenses, exams, cleanings, and basic restorative services. Prescription drug coverage (mail and retail) is subject to 20% coinsurance after the deductible is met.

Keystone Health Plan East HMO Individual Plans – Compare Rates

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Keystone Health Plan East HMO plans are available to individuals and families who live in Southeastern Pennsylvania. We help you compare the most affordable Independence Blue Cross policies on and off the Exchange and easily apply for coverage. If you reside in the counties of Bucks, Montgomery, Chester, Philadelphia or Delaware, you can purchase private or small business benefits through our website. Services also extend to New Jersey and Delaware.

Pa Keystone HMO plans allow you to organize your medical treatment through a primary care provider (pcp). With almost 21,000 network physicians available, it’s easy to find a doctor, specialist, hospital, or other medical facility that’s located within minutes of your work or residence. Currently there are six available options which include one Platinum, two Gold, two Silver and a Bronze.


These six plans are offered through the Pa Marketplace and are eligible for the federal subsidy, which began in 2014. You choose a primary care physician that is typically your first contact if you need treatment. If specialized or emergency aid is needed, you are referred to other providers within the network. Deep discounts are usually provided when you stay “in-network.” ER expenses are an exception, since often you need immediate aid and can’t choose the facility.

Treatment  outside of the network often results in higher deductibles and/or out-of-pocket expenses. When scheduling surgeries or procedures, it’s important to verify that all of your treatment will be performed by in-network providers. Typically, verification can be completed online or by directly asking the physician or facility.

Note: If you are over age 65 and/or eligible for Medicare, you can compare the best Medigap plans in Pennsylvania since you would not need an “under-65” policy. “Advantage” options are also available, which usually eliminate most of the premium. Part D (prescription) benefits are also available.

Naturally, the higher the deductible (Bronze) or copay you select, the lower the premium will be. And there are plenty of available providers to find in the area. Skipping almost all paperwork when a claim is filed is a very popular feature. You also can change from a current pcp to another at any time. There are are no fees or charges and the process is very quick.

There are also numerous PPO plans that are also available. Typically, out-of-pocket costs are higher, although you do not need to have a pcp to coordinate and oversee your treatment. There is a wider selection of physicians, specialists and hospitals to utilize, although once again, if you stray away from the provider list, you pay much more. Also, PPO coverage generally costs more than HMO coverage.

Available Policies

The available policies for individuals and families are Platinum, Gold, Gold Proactive, Silver, Silver Proactive, and Bronze. The Platinum plan is the most expensive option while the Bronze, which features higher out-of-pocket expenses, is the least expensive plan.

Each of these six plans (discussed in detail below) contains 10 “Essential Health Benefits” (required by law). Specifically, these benefits are: preventive and wellness, pediatric treatment (including dental), hospitalization, mental illness and substance abuse,  lab services, ER care, rehabilitation and habilitation, prescriptions, and maternity. Of course, there are many other coverages in addition to these 10 benefits.

Pa IBX Maternity Coverage

Maternity Coverage Is Included On All Pa Keystone HMO Plans

Proactive Tiers

“Proactive” plans are divided into three “tiers” (preferred, enhanced and standard) that allow you to choose cost-saving providers. The preferred tier physicians and facilities cost the least while the standard tier providers cost the most. Often, you can choose the level of pricing, although all providers must meet strict Keystone standards.

This concept allows consumers the opportunity to save money on most treatment, but still receive treatment from providers that have to meet the highest possible quality standards. And you can mix and match different services with different tiers.

Although preventive services, mental illness,  emergency room treatment and most therapies have identical tiers, other services will have multiple tiers. Upon request, we will provide an online link that allows you to view and compare different options in your area. About half of all doctors are in the preferred tier and any adjustments are made once per year.

It’s important to note that physicians with multiple locations can have more than one assigned tier. For example, a specific location may have lower expenses, and thus charge a lower price than another office location in a “high-rent” district.

Six  HMO Plans

More specific details about each of the six available HMO plans are listed below:

Platinum – No deductible or coinsurance highlights this “Cadillac” plan. The maximum out-of-pocket cost is $3,000 for an individual and $6,000 for a family. Office visit/specialist copays are $15 and $30 respectively, and brand-name drugs are only subject to a $30 copay. If you are hospitalized, the admission fee is $400 per day (not to exceed $2,000). The ER charge is $250.

Gold – The out-of-pocket expenses are significantly higher than the Platinum plan ($6,100 and $12,200) as are the copays ($25 and $60) for primary care physicians and specialists. The hospital admission copay is bumped up to $750 and prescription copays are also higher.

Gold Proactive – There are no deductibles although the maximum out-of-pocket expense is $6,350 per person and $12,700 per family. Since it is a tiered plan, office visit (PCP) copays are $15, $30 or $45, depending upon the tier of physicians you choose. Specialist copays are $40, $60 and $80, once again, depending upon the tier you select.

Your in-hospital daily stay maximum is only $350 in the preferred tier, but $1,100 in the standard tier. Maternity, outpatient expenses, and outpatient surgeries all have major variances between tiers. Also, retail clinics will receive the preferred tier pricing with the exception of Walgreens Healthcare Clinics, which are always billed in the standard tier. A comparison of all three Gold plans (2 HMO and 1 PPO) are found below:

Keystone HMO Gold Plans In Pennsylvania

Silver – The Silver plan, unlike the Gold and Platinum options, does have a deductible ($2,000 individual and $4,000 family). There is also 30% coinsurance and $35/$70 office visit copay combinations. The generic drug copay is $10, so in many situations, paying  for the prescription yourself results in minor savings. Retail brand and non-formulary drugs, however, have a 50% coinsurance although your cost is limited to $250.

Silver Proactive – There is no deductible in the “preferred” tier, which provides a huge incentive to utilize that specific network. Otherwise, a $3,000 deductible applies. Copays are $20 and $45 for office visits and a $400 maternity and/or hospital inpatient per day charge applies (maximum five copays). Once again, if you use the enhanced or standard tiers, a deductible applies and the per-day expense substantially increases.

Bronze – $6,000 individual ($12,000 family) deductible with 0% coinsurance make this plan one of the cheapest Exchange policies available. Office visit copays are $40 and $80 respectively with a low $40 copay to retail clinics. 30 occupational or physical therapy visits are allowed with a $60 copay.


Blue Cross HMO Plans

Keystone HMO Plans Provide Comprehensive Benefits


Prescription Benefits

More than 50,000 national and local locations can be used to fill or renew your generic and non-generic RX needs. Both mail-order and direct pick-up are available. “FutureScripts,” an independent company affiliated with IBX, administers the prescription program for all members. A unique ID card is provided to streamline the process when you visit any location.

“FutureScripts” is included on the HMO Bronze, HMO Silver Proactive and HMO Gold Proactive plans. Important To Note: Walgreens and RiteAid are considered “outside of network” with FutureScripts and you will incur higher out-of-pocket expenses if you use these pharmacies. However, $4 generic drugs are offered on all policies except the Platinum option.

There is no maximum annual or lifetime benefit, so you can not “run out” of prescription coverage. However, copays, deductibles and out-of-pocket expenses will vary, depending on the plan you choose. Naturally, the Platinum and Gold plans (both HMO and PPO) will have more inclusive coverage than Bronze Metal plans, including copays rather than deductibles. Birth control (oral and injectable contraceptives) are considered “preventive” and are covered.

Free Medicine

Yes…Some medications are free, since they are considered “preventive medications,” and no copay or deductible applies. Many pharmacies will provide these drugs in person, and through mail order. The following classes of drugs qualify:

Get Many Free Medicines On Pa Healthcare Plans

Many Free Preventive Prescriptions Are Available

Vitamin D supplements to Seniors over the age of 65.

Tobacco interventions for current smokers.

Folic acid supplements for females that are either pregnant or contemplating having a baby.

Iron supplements for children at risk.

Breast cancer chemotherapy preventive medications.

Fluoride supplements for children (Specific age limits apply).

Maternity Included

Prior to 2014, many individual plans either excluded maternity benefits, limited coverage, added a waiting period (often as much as 270 days) or charged thousands of dollars extra to add it as a rider. For all Marketplace tier policies (including Keystone Health Plan East), these exclusions and extra charges have been eliminated. In fact, during Open Enrollment, if you are pregnant, you can secure coverage in 15 days.

In addition to complete (100%) preventive benefits before and after delivery, prenatal visits (including preconception) are covered. Your gynecological history including birth control, obstetric history, current medications and existing allergies will be initially discussed. Vaccinations, lifestyle information and genetic screening may also be covered, if relevant to your situation. First, second and third trimester visits will be part of the benefit package.

Additional benefits available (if needed) include alcohol addiction screening, tobacco counseling and cessation programs, iron deficiency screening, infection screening and gestational diabetes prevention and screening. A glucose-screening test is quite routine during pregnancy, since it is one of the most common medical issues for expectant mothers.

Breastfeeding support and counseling (and supplies) is typically partially or fully covered. Lactation support and rental of breast pumps is also a covered benefit, subject to some restrictions and limitations. We also utilize this pregnancy resource that provides in-depth information on a week-by-week and trimester basis.

Enrollment Process

Enrolling is much easier than the initial (2014) rollout of ACA plans. Often the process took between 45 minutes and two hours. That was too long! The total application time should now take between 15 and 20 minutes. We have simplified the entire procedure through a combination of updated software and the streamlined ACA application. If you aren’t eligible for the federal subsidy, the process will actually be quicker!

Many policies have changed from last year, including shrinking provider networks, additional preventive benefits, and tier designations. To ensure you apply for the most suitable policy and maximize your subsidy (if applicable), we always recommend calling or emailing us before you enroll. A quick 10-minute review could potentially save you thousands of dollars,

Additional Perks

Included in your membership are programs that promote wellness and help you manage your treatment in the most effective and least costly manner, especially if you have chronic conditions. Coaches and nurses are available 24/7 and assistance with critical medical decisions are provided. “Lifestyles” programs are also provided that include valuable discounts for many products and memberships.


January 27 2015 – “Blue Insider” is now available to policyholders.  It became effective yesterday and will offer a multitude of events, attractions, and products at a substantial discount (up to 60%). By utilizing their exclusive “Working Advantage” portal, members can save money on the following items:

Movies, zoos, theatrical events, concerts, sporting events, restaurants, and parks. Also, many consumer products will be discounted including books, electronics, food establishments, and clothing.

February 9 2015 – Through January 15th, more than 175,000 persons had enrolled in Exchange plans in the five-county Keystone service area. More than 400,000 persons have purchased policies in the entire state as of February 1. Silver and Bronze-tier plans continue ti be the most popular policies and most applicants receive some type of federal funding to help lower the premium.