Summary of Benefits

The Summary of Benefits tells you about some of the plan’s features. You should refer to the Summary of Benefits for:

• benefits
• premiums
• cost-sharing (e.g., copays, coinsurance, and deductibles)

For a copy of the Summary of Benefits:

Download a 2014 Summary of Benefits in PDF format:

• Keystone 65 Select and Preferred HMO Y0041_H3952_KS_14_8161 Accepted 9/18/2013
• Personal Choice 65^SM PPO Y0041_H3909_PC_14_8162 Accepted 9/17/2013

Submit an online request for a copy to be mailed to your home.

• Call us at 1-877-393-6733 (1-877-219-5457 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please be aware that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

The Summary of Benefits doesn’t list every service we cover or list every limitation or exclusion. To get a detailed list of our benefits, please refer to the Evidence of Coverage.

Extra help is available for those who need it most. Find out whether you qualify for low-income subsidy.

Website last updated: 12/16/2013
Y0041_HM_14_9866e Approved 1/27/2014