Keystone 65 Select HMO

Now get the Independence Blue Cross quality and dependability you want in a Medicare health plan...for less!

Keystone 65 Select HMO — as low as $15 per month.*

  • All the doctor and hospital coverage you get under Original Medicare
  • SilverSneakers®** fitness membership
  • Optional prescription drug coverage
  • Optional preventive dental, eyewear, and hearing aid benefits

ibxmedicare.com Summary of Benefits Y0041_H3952_KS12_03a CMS Approved 09082011.

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* Members must continue to pay Medicare Part A, if applicable, and Part B premiums. Limitations, copayments, and restrictions may apply.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan.

** SilverSneakers is a program of Healthways, Inc., an independent company.


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 donít 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 Approved 7/27/2012