1-800-303-0656
(TTY/TDD: 711) 8 a.m. - 8 p.m.*
(TTY/TDD: 711) 8 a.m. - 8 p.m.*
The Ask IBX tool does not have a direct connection to a real "live" representative, but instead accesses a database of commonly/frequently asked questions.
Organizational determination is the process by which the plan makes a decision about whether a service provided for you is covered and the amount, if any, you are required to pay. You, your physician, or your representative may make an oral or written, standard or expedited request.
If you are a Keystone 65 HMO member, you can request an organizational determination by using one of the methods below.
If you are a Personal Choice 65SM PPO member, you can file an organizational determination by using one of the methods below.
For more information on Keystone 65 Select Medical-only HMO’s organizational determination process, please reference Chapter 7, Section 4 on page 99 in your EOC or click on the link below.
Keystone 65 Select Medical-only HMO Organizational Determination Instructions
Y0041_H3952_KS_14_9262 Accepted 9/12/2013
For more information on Keystone 65 Preferred Medical-only HMO’s organizational determination process, please reference Chapter 7, Section 4 on page 97 in your EOC or click on the link below.
Keystone 65 Preferred Medical-only HMO Organizational Determination Instructions
Y0041_H3952_KS_14_9264 Accepted 9/12/2013
For more information on Keystone 65 Select Rx HMO’s organizational determination process, please reference Chapter 9, Section 4 on page 153 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Organizational Determination Instructions
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO’s organizational determination process, please reference Chapter 9, Section 4 on page 150 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Organizational Determination Instructions
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For more information on Personal Choice 65SM Medical-only PPO’s organizational determination process, please reference Chapter 7, Section 4 on page 100 in your EOC or click on the link below.
Personal Choice 65 Medical-only PPO Organizational Determination Instructions
Y0041_H3909_PC_14_8450 Accepted 9/12/2013
For more information on Personal Choice 65SM Rx PPO’s organizational determination process, please reference Chapter 9, Section 4 on page 154 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Organizational Determination Instructions
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
For Keystone 65 Select and Preferred HMO members, the plan requires prior authorization (approval in advance) of certain covered medical services. Some in-network medical services are covered only if your doctor or other network provider gets prior authorization from the plan. Your in-network provider can request a medical prior authorization on your behalf.
For more information on Keystone 65 Select Medical-Only HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 41 in your EOC or click on the link below.
Keystone 65 Select Medical-Only HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_14_9262 Accepted 9/12/2013
For more information on Keystone 65 Preferred Medical-Only HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 41 in your EOC or click on the link below.
Keystone 65 Preferred Medical-Only HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_14_9264 Accepted 9/12/2013
For more information on Keystone 65 Select Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 50 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 49 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Prior Authorization and Benefits Chart
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For Personal Choice 65SM PPO members, the plan requires prior authorization (approval in advance) of certain covered medical services. In the network portion of a PPO, some in-network medical services are covered only if your doctor or other network provider gets prior authorization from our plan. In a PPO, you do not need prior authorization to obtain out-of-network services, but you can ask the plan to make a coverage decision in advance.
For more information on Personal Choice 65SM Medical-Only PPO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 37 in your EOC or click on the link below.
Personal Choice 65 Medical-Only PPO Prior Authorization and Benefits Chart
Y0041_H3909_PC_14_8450 Accepted 9/12/2013
For more information on Personal Choice 65SM Rx PPO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2 on page 46 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
Your in-network provider can request a medical prior authorization on your behalf.
If you, your doctor, or your representative do not agree with the outcome of the initial coverage determination, appeal the decision by requesting a redetermination. Learn more about the medical appeals process by reviewing your Evidence of Coverage (EOC).
If you are a Keystone 65 HMO member, you can file a standard or expedited medical appeal by using one of the methods below.
If you are a Personal Choice 65SM PPO member, you can file a standard or expedited medical appeal by using one of the methods below.
For more information on Keystone 65 Select Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 99 in your EOC or click on the link below.
Keystone 65 Select Medical-only HMO Medical Appeals
Y0041_H3952_KS_14_9262 Accepted 9/12/2013
For more information on Keystone 65 Select Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 153 in your EOC or click on the link below.
Keystone 65 Rx HMO Medical Appeals
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 97 in your EOC or click on the link below.
Keystone 65 Preferred Medical-only HMO Medical Appeals
Y0041_H3952_KS_14_9264 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 150 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Medical Appeals
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For more information on Personal Choice 65SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 100 in your EOC or click on the link below.
Personal Choice 65 Medical-only PPO Medical Appeals
Y0041_H3909_PC_14_8450 Accepted 9/12/2013
For more information on Personal Choice 65SM Rx PPO Medical Appeals, please reference Chapter 9, Section 5 on page 157 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Medical Appeals
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
You may file a grievance if you have a complaint other than one that involves a coverage determination (see Appeals above). You would file a grievance for any type of problem you might have with us or one of our network providers.
If you are a Keystone 65 HMO Member, you can file a standard or expedited grievance by using one of the methods below.
If you are a Personal Choice 65SM PPO Member, you can file a standard or expedited grievance by using one of the methods below.
For more information on Keystone 65 Select Medical-only HMO Grievances, please reference Chapter 7, Section 9 on page 131 in your EOC or click on the link below.
Keystone 65 Select Medical-only HMO Grievances
Y0041_H3952_KS_14_9262 Accepted 9/12/2013
For more information on Keystone 65 Select Rx HMO Grievances, please reference Chapter 9, Section 10 on page 199 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Grievances
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Medical-only HMO Grievances, please reference Chapter 7, Section 9 on page 130 in your EOC or click on the link below.
Keystone 65 Preferred Medical-only HMO Grievances
Y0041_H3952_KS_14_9264 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO Grievances, please reference Chapter 9, Section 10 on page 196 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Grievances
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For more information on Personal Choice 65SM Medical-only PPO Grievances, please reference Chapter 7, Section 9 on page 131 in your EOC or click on the link below.
Personal Choice 65 Medical-only PPO Grievances
Y0041_H3909_PC_14_8450 Accepted 9/12/2013
For more information on Personal Choice 65SM Rx PPO Grievances, please reference Chapter 9, Section 10 on page 200 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Grievances
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
Coverage determination is the process by which the plan makes a decision about whether a Part D drug prescribed for you is covered and the amount, if any, you are required to pay. An initial coverage decision about your Part D drugs is called a ‘coverage determination.’ You, your doctor, or someone you’ve authorized may make an oral or written, standard or expedited request.
If you are a Keystone 65 Rx HMO member, you can file a coverage determination by using one of the methods below.
If you are a Personal Choice 65SM Rx PPO member, you can file a coverage determination by using one of the methods below.
coverage determination form. Y0041_HM_12_1109 File & Use 01/15/2012As part of the coverage determination process, you can ask us to make an exception, including requesting coverage of drug that is not on the formulary, waiving restrictions on the plan's coverage for a drug or asking to pay a lower-cost sharing amount. This process is called a “formulary or tier cost-sharing exception.” You may use the Coverage Determination Form to request an exception.
Coverage Determination Form for Enrollees
Coverage Determination Form for Providers
For more information on Keystone 65 Select Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 167 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO’s coverage determination process, please reference Chapter 9, Section 6 on page 164 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Coverage Determination Instructions
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For more information on Personal Choice 65SM Rx PPO’s coverage determination process, please reference Chapter 9, Section 6 on page 168 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Coverage Determination Instructions
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
For certain Part D drugs, you, your physician, or representative may need to obtain prior authorization from us before we will cover the drug.
For Keystone 65 Select and Preferred HMO members, the plan requires prior authorization (approval in advance) of certain covered prescription drugs that have been approved by the FDA for specific medical conditions.
For more information on Keystone 65 Select Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 96 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Prior Authorization for Part D Drugs
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 93 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Prior Authorization for Part D Drugs
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For Personal Choice 65SM PPO members, the plan requires prior authorization (approval in advance) of certain covered and prescription drugs that have been approved by the FDA for specific medical conditions.
For more information on Personal Choice 65SM Rx PPO’s prior authorization process and what services require prior authorization, please reference Chapter 5, Section 4 on page 97 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Prior Authorization for Part D Drugs
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
If you, your doctor, or your representative do not agree with the outcome of the initial coverage determination, appeal the decision by requesting a redetermination. Learn more about the appeals process by reviewing your Evidence of Coverage (EOC).
If you are a Keystone 65 HMO member, you can file a standard or expedited Part D appeal by using one of the methods below.
If you are a Personal Choice 65SM PPO member, you can file a standard or expedited Part D appeal by using one of the methods below.
For more information on Keystone 65 Select Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 167 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Part D Appeals
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO Part D Appeals, please reference Chapter 9, Section 6 on page 164 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Part D Appeals
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For more information on Personal Choice 65SM Rx PPO Part D Appeals, please reference Chapter 9, Section 6 on page 168 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Part D Appeals
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
You may file a grievance if you have a complaint other than one that involves a coverage determination (see Part D Appeals above). You would file a grievance for any type of problem you might have with us or one of our network pharmacies.
If you are a Keystone 65 HMO Member, you can file a standard or expedited Part D grievance by using one of the methods below.
If you are a Personal Choice 65SM PPO Member, you can file a standard or expedited Part D grievance by using one of the methods below.
For more information on Keystone 65 Select Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 199 in your EOC or click on the link below.
Keystone 65 Select Rx HMO Part D Grievances
Y0041_H3952_KS_14_9263 Accepted 9/12/2013
For more information on Keystone 65 Preferred Rx HMO Part D Grievances, please reference Chapter 9, Section 10 on page 196 in your EOC or click on the link below.
Keystone 65 Preferred Rx HMO Part D Grievances
Y0041_H3952_KS_14_9265 Accepted 9/12/2013
For more information on Personal Choice 65SM Rx PPO Part D Grievances, please reference Chapter 9, Section 10 on page 200 in your EOC or click on the link below.
Personal Choice 65 Rx PPO Part D Grievances
Y0041_H3909_PC_14_8451 Accepted 9/12/2013
If you have someone appealing our decision for you other than your physician, your appeal must include an "Appointment of Representative" form. The person taking action on your behalf is called an appointed representative. You can name a relative, friend, advocate, lawyer, or anyone else to be your appointed representative. If you want someone to act for you, then you and that person must sign and date an "Appointment of Representative" form that authorizes the person to act as your appointed representative
This statement must be sent to us at:
Medicare Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652
You can call Customer Service to learn how to name your appointed representative. Learn more about the appointed representative process:
The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage and is considered a legal document. Use the EOC for information on the grievance, coverage determination, and appeals processes.
Keystone 65 Select Medical-Only and Keystone 65 Select Rx; and Keystone 65 Preferred Medical Only and Keystone 65 Preferred Rx:
c/o Service Center
PO Box 69353
Harrisburg, PA 17106-9353
Personal Choice 65 Medical-Only and Personal Choice 65 Rx:
c/o Service Center
PO Box 69352
Harrisburg, PA 17106-9352
Members and providers who have questions about the exceptions and appeals processes, would like to inquire about the status of a coverage determination or appeal request, or would like aggregate statistical data on the number of grievances, appeals, and exceptions filed with the plan, please contact Customer Service.
Website last updated: 9/30/2014
Y0041_HM_15_20730 Approved 10/06/2014