Keystone 65 HMO

2013 Overview

Enroll in a plan

Medicare Advantage plans designed to fit your needs
Everyone’s insurance needs are different. This is why there are six different Medicare Advantage plans for you to choose from. No matter what type of coverage you are looking for — Keystone 65 HMO has the plan for you.

Keystone 65 Select HMO plan options


Keystone 65 Select HMO	Medical-only coverage
Keystone 65 Select HMO with Choice Program	Medical coverage + hearing, dental, and vision coverage

Keystone 65 Select Rx HMO	Medical coverage + prescription drug coverage

Keystone 65 Select Rx HMO with Choice Program	Medical coverage + hearing, dental, and vision coverage + prescription drug coverage

Keystone 65 Preferred HMO plan options


Keystone 65 Preferred HMO	Medical coverage (includes hearing, dental, and vision)
Keystone 65 Preferred Rx HMO	Medical coverage (includes hearing, dental, and vision) + prescription drug coverage

With any of the Keystone 65 HMO plans:

You choose a primary care physician (PCP) from your plan’s provider network.
- Please note that Keystone 65 Select HMO and Keystone 65 Preferred HMO have different provider networks.
Your PCP arranges referrals to the other doctors, hospitals, and health care services you need within the network.
There is no need to submit claim forms for most services: simply show your Keystone 65 HMO ID card when you obtain medical services.

All Keystone 65 HMO plans include:

Comprehensive medical coverage with virtually no paperwork;
Routine medical exams, screenings, and preventive care;
Access to an extensive network of more than 1,900 primary care physicians, 27,000 specialist sites, and 70 hospitals;
Access to health resources and wellness programs;
Help managing chronic conditions, such as asthma, diabetes, and COPD;
If you choose a plan with prescription drug coverage:
- You’ll have the convenience of paying just one premium each month for both your medical and drug coverage.
- You may go to thousands of pharmacies within the network and simply present your Keystone 65 HMO card. Learn more about prescription drug coverage.
If you choose a plan with hearing, dental, and vision coverage:
- You’re covered for routine dental exams and cleanings every six months.
- You’re also covered for vision and hearing services — and can get reimbursements for eyewear and hearing aids.


Keystone 65 Select HMO (medical-only plan)	Medical coverage (includes hearing, dental, and vision): PCP Visit: $15 copayment Specialist Visit: $45 copayment Prescription Drugs: Not Covered Emergency Room: $65 copayment - not waived if admitted. Emergency care is offered worldwide. Ambulance: $100 copayment Urgent Care: $25 - In-network Urgent Care Centers; $15 PCP - $45 Specialist; copayment depends on provider type Inpatient Hospital: $245/day; days 1 - 7; $0 copayment for additional days per stay; $1,715 maximum per stay Preventive Services: $0 copayment Health/Wellness Education: Programs include: SilverSneakers, Weight Management, Smoking Cessation, and Disease Management Medicare Deductible: $0 - No Deductible
Keystone 65 Select HMO with Choice Program (medical-only plan)	Keystone 65 Select HMO benefits listed above plus: Dental Benefits: $15 copayment (one exam/cleaning every six months) Eyewear: $100 (every two years) Eye exam: $0 copayments (1 exam every two years) Hearing Aids: Up to $500 for two aids (every three years) Hearing exams: $45 copayment (1 exam every three years)
Keystone Select Rx HMO (medical plus prescription drug)	Medical coverage (includes hearing, dental, and vision) + prescription drugs: PCP Visit: $15 copayment Specialist Visit: $45 copayment Prescription Drugs: $280 Deductible; $4 generic/$40 preferred brand/$80 non-preferred brand/25% coinsurance specialty drugs; once you have reached $2,970 in total drug costs you will pay 79% for generic drugs and 47.5% for brand-name drugs. You will pay the greater of $2.65 generic and $6.60 brand or 5% coinsurance after reaching the $4,750 catastrophic stage. Mail Order is Available. Emergency Room: $65 copayment - not waived if admitted. Emergency care is offered worldwide. Ambulance: $100 copayment Urgent Care: $25 - In-network Urgent Care Centers; $15 PCP - $45 Specialist; copayment depends on provider type Inpatient Hospital: $245/day; days 1 - 7; $0 copayment for additional days per stay; $1,715 maximum per stay Preventive Services: $0 copayment Dental Benefits: Not covered Eyewear: Not covered Hearing Aids: Not covered Health/Wellness Education: Programs include: SilverSneakers, Weight Management, Smoking Cessation, and Disease Management Medicare Deductible: $0 - No Deductible
Keystone Select Rx HMO with Choice Program (medical plus prescription drug)	Keystone 65 Select Rx HMO benefits listed above plus: Dental Benefits: $15 copayment (one exam/cleaning every six months) Eyewear: $100 (every two years) Eye exam: $0 copayments (1 exam every two years) Hearing Aids: Up to $500 for two aids (every three years) Hearing exams: $45 copayment (1 exam every three years)

Keystone 65 Preferred HMO (medical-only plan)	Medical coverage (includes hearing, dental, and vision): PCP Visit: $5 copayment Specialist Visit: $40 copayment Prescription Drugs: Not Covered Emergency Room: $65 copayment - not waived if admitted. Emergency care is offered worldwide Ambulance: $100 copayment Urgent Care: $20 - In-network Urgent Care Centers; $5 PCP - $40 Specialist; copayment depends on provider type Inpatient Hospital: $215/day; days 1 - 7; $0 copayment for additional days per stay; $1,505 maximum per stay Preventive Services: $0 copayment Dental Benefits: $15 copayment (one exam/cleaning every six months) Eyewear: $100 (every two years) Eye exam: $0 copayments (1 exam every two years) Hearing Aids: Up to $500 for two aids (every three years) Hearing exams: $45 copayment (1 exam every three years) Health/Wellness Education: Programs include: SilverSneakers, Weight Management, Smoking Cessation, and Disease Management Medicare Deductible: $0 - No Deductible
Keystone 65 Preferred Rx HMO (medical plus prescription drug)	Medical coverage (includes hearing, dental, and vision) + prescription drugs: PCP Visit: $5 copayment Specialist Visit: $40 copayment Prescription Drugs: $100 Deductible; $5 generic/$40 preferred brand/$80 non-preferred brand/25% coinsurance specialty drugs; once you have reached $2,970 in total drug costs you will pay a $5 copay for generic drugs and 47.5% for brand-name drugs. You will pay the greater of $2.65 generic and $6.60 brand or 5% coinsurance after reaching the $4,750 catastrophic stage. Mail Order is Available. Emergency Room: $65 copayment - not waived if admitted. Emergency care is offered worldwide. Ambulance: $100 copayment Urgent Care: $20 - In-network Urgent Care Centers; $5 PCP - $40 Specialist; copayment depends on provider type Inpatient Hospital: $215/day; days 1 - 7; $0 copayment for additional days per stay; $1,505 maximum per stay Preventive Services: $0 copayment Dental Benefits: $15 copayment (one exam/cleaning every six months) Eyewear: $100 (every two years) Eye exam: $40 copayments (1 exam every two years) Hearing Aids: Up to $500 for two aids (every three years) Hearing exams: $45 copayment (1 exam every three years) Health/Wellness Education: Programs include: SilverSneakers, Weight Management, Smoking Cessation, and Disease Management Medicare Deductible: $0 - No Deductible

Contact Us

Prospective members can call 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.
Members can call 1-800-645-3965 (1-888-857-4816 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week.
Send us an email.
Prospective members can mail any inquiries to P.O. Box 13713, Philadelphia, PA 19101-3713.
Members can mail any inquiries to P.O. Box 7799, Philadelphia, PA 19101-7799

Summary of Benefits

For details of covered services, copays, and deductibles for the Keystone 65 HMO plans, see the ibxmedicare.com Summary of Benefits. Y0041_H3952_KS_13_2337 Accepted 09/23/2012