Manuals, Guides, and Forms
Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information.
HIPAA Privacy Practices and Forms contains privacy information and documentation related to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The Summary of Benefits tells you about some of the plan’s features, including conditions and limitations, premiums, and cost-sharing.
The Evidence of Coverage is a comprehensive resource guide to your health care coverage. It explains your benefits, exclusions, and plan rules.
Change form
Please keep in mind that you cannot use a change form to switch between Personal Choice 65SM PPO, a Blue Cross Medicare Advantage PPO Plan and Keystone 65 HMO, a Blue Cross Medicare Advantage HMO Plan from Keystone Health Plan East.
Change Plans online:
Or complete and mail one of the following forms:
Keystone 65 HMO
- Keystone 65 HMO Change Form (Phila/Bucks) Y0041_HM12_50 CMS Approved 08/26/2011
- Keystone 65 HMO Change Form (Chest./DelCo/MontCo.) Y0041_HM12_50 CMS Approved 08/26/2011
Mail to:
Keystone 65 HMO
PO Box 7799
Philadelphia PA 19101-9746
Personal Choice 65
- Personal Choice 65 PPO Change Form Y0041_HM12_50 CMS Approved 08/26/2011
Mail to:
Personal Choice 65 PPO
PO Box 7799
Philadelphia PA 19101-9746
Disenrollment Forms
If you wish to request disenrollment from the plan, please use the appropriate form for your plan.
- Personal Choice PPO Disenrollment Form Y0041_H3909_PC12_669 CMS Approved 10/11/2011
- Keystone 65 HMO Disenrollment Form Y0041_H3952_KS12_667 CMS Approved 10/07/2011
- Select Option PDP Disenrollment Form
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
Help us to reduce expenses and preserve our natural resources by signing up to receive electronic communications from Independence Blue Cross.
Registration is quick and simple, and all transactions are secure.
