Evidence of Coverage

The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage. It explains your benefits, premiums, and cost-sharing; conditions and limitations of coverage; and plan rules.

After you’ve joined the plan, you will receive the Evidence of Coverage in the mail. This is a legal document that should be kept in a safe place.

2012

Errata Sheets

The information contained in these errata sheets replaces certain language and/or benefits found in your Evidence of Coverage. Please refer to these documents along with the EOC for information about your plan’s benefits.

For Keystone 65 HMO Medical-Only:

For Keystone 65 HMO Medical with Prescription Drug:

For Personal Choice 65 PPO Medical-Only:

For Personal Choice 65 PPO Medical with Prescription Drug:

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions. Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
  • Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

Medicare beneficiaries may enroll in Keystone 65 HMO, Personal Choice 65 PPO, or Select Option PDP through the CMS Medicare Online Enrollment Center located at www.medicare.gov.

You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Keystone 65 HMO or Personal Choice 65 PPO will be responsible for the costs.

Please contact Keystone 65 HMO or Personal Choice 65 PPO Customer Service for more information.

Website last updated: 3/6/12
Y0041_HM_12_300a Pending CMS Approval

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