Medical Plan Options
PENNCare/Personal Choice
This is a Preferred Provider Organization (PPO) administered by Independence Blue Cross. You may use any provider you wish, but the plan limits your out-of-pocket expense when you utilize the PENNCare or Personal Choice networks of preferred providers. You do not have to choose a primary care physician or obtain referrals under the PENNCare/Personal Choice plan.
The PENNCare/Personal Choice Plan has three parts:
- PENNCare preferred providers - Use physicians, hospitals, and other health care providers who are part of or affiliated with the University of Pennsylvania Health System (UPHS) provider network. When you use a provider in this network, you do not have to meet a deductible and the plan pays 100% (after applicable co-payments) for most services with the exception of mental health care.
- Personal Choice preferred providers - Use physicians, hospitals, and other health care providers who are part of the Independence Blue Cross Personal Choice provider network. This is a very comprehensive network encompassing a large number of providers in the Pennsylvania, New Jersey, and Delaware area. When you use a provider in this network, the plan pays 100% (after applicable co-payments) for many services, such as physician office visits, outpatient x-rays and labs, emergency care, pediatric immunizations, routine gynecological care, and maternity care. Other services are paid at 80% subject to deductibles, co-insurance, and out-of-pocket maximums.
- Non-Preferred providers - Use physicians, hospitals, and other health care providers who are not part of either the PENNCare or Personal Choice provider networks. When you use this level of benefits, note that payment for services is based on the negotiated rate and you must file claim forms. The plan pays 100% of the negotiated rate for emergency medical care. All other services are paid at 70% of the negotiated rate subject to deductibles, co-insurance, and out-of-pocket maximums.
UPHS Point of Service (POS) Administered by Keystone/AmeriHealth*
This is a Managed Care Plan that pays for preventive care and care when you are ill. You can receive low cost care by using the network and obtaining referrals from your network Primary Care Physician (PCP).
The plan has two parts:
- Referred Care provided through the University of Pennsylvania Health System Provider Network (UPHS) and the Keystone/AmeriHealth* Provider Network. Referred Care is care coordinated through your Primary Care Physician and paid at 100%, after an office visit co-payment, for most services.
- Self-Referred Care is care you receive without a referral or from a non-network provider. Most services are covered at 80% of the Plan's UCR and are subject to deductibles, co-insurance and out-of-pocket maximums. Some services are not covered if rendered by a non-network provider.
* This plan is administered by AmeriHealth in certain areas.
Health Maintenance Organization (HMO)
HMOs are Managed Care Plans. There are two PennChoice HMOs:
Keystone Health Plan East/AmeriHealth* and Aetna. In these Plans,
your care is coordinated through a Primary Care Physician. HMOs pay
for preventive care and care when you are ill. There are co-pays for
physician's office visits - most other medical services are paid in
full. In general, you must receive medical services from preferred
providers (physicians, hospitals, etc.) that are part of the HMO network,
and you must have referrals from your Primary Care Physician in order for
most participating specialist services to be paid by the HMO.
* This plan is administered by AmeriHealth in certain areas.
Waiving Medical Coverage
If you have medical coverage through another source, you may elect to waive
medical coverage.