INDIVIDUAL HMO SUBSCRIBER AGREEMENTHmo Subscriber Agreement • October 8th, 2015
This HMO Subscriber Agreement sets forth a comprehensive program of Inpatient and outpatient health care benefits for Subscribers and their eligible Dependents who reside and obtain Covered Services from Participating Providers within Keystone’s Limited Network Area, which is a geographical area consisting of the following eight (8) Pennsylvania counties: Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Northampton and Perry. Keystone’s Limited Network Area is a limited geographic area within the full twenty- one (21) county area in which Keystone is approved to operate as an HMO. (“Keystone’s Approved Service Area”). Subscribers and their eligible Dependents may obtain the full range of Covered Services from Participating Providers only in Keystone’s Limited Network Area, subject to the terms and conditions of this Subscriber Agreement. In most cases, Members must obtain Referrals for Covered Services, and benefits are provided only for services performed by a Participating Pro
