Medical Policy

Terms and Conditions

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• The Policy Bulletins on this website were developed to assist Independence Blue Cross (“IBC”) in administering the provisions of its benefits programs and do not constitute medical advice. If you are an IBC member, please refer to your specific Evidence of Coverage book for the terms, conditions, limitations and exclusions of your coverage. Facility and professional providers, such as hospitals and physicians, are responsible for providing medical advice and treatment. If members have a specific medical condition or question, they should consult with their provider.
• Currently, the Policy Bulletins available on this website represent only a portion of the Policy Bulletins used by IBC. IBC intends to expand the number of Policy Bulletins available on this website in the near future. Please note that the Policy Bulletins are updated biennially and when new medical evidence becomes available and, therefore, are subject to change.
• You should be aware that Policy Bulletins are used as a guide only. Coverage decisions are made by applying Policy Bulletin criteria to the member’s medical history, condition and proposed course of treatment as well as the member’s benefit program. Members should review the Policy Bulletins with their providers because the Policy Bulletins are designed to be used by our professional staff in making decisions about your coverage and can be highly technical.
• Information contained in the Policy Bulletins does not constitute an offer of coverage, medical advice or guarantee of payment. Please note that, if there is a conflict between the Policy Bulletin and a member’s benefit program, the terms of the benefit program will govern, which can be found in your Evidence of Coverage.
• Current Procedural Terminology (CPT^®). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

CPT^® is a trademark of the American Medical Association.

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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.”

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-are 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.

Y0041_HM_12_300a Pending CMS Approval