Personal Choice 65^SM PPO

Overview

• Overview
• Monthly Premiums
• Frequently Asked Questions
• Prescription Coverage
• Eligibility Requirements

Enroll in a plan

Freedom to go to any doctor or hospital in the U.S. — without a referral

With Personal Choice 65 PPO you’ll get more coverage than Original Medicare and a Medicare supplement, and you’ll pay less — or nothing at all — for preventive care. You can also choose to add prescription drug coverage to your plan, and you’ll pay less for your prescription drugs.

With Personal Choice 65 PPO:

• You don’t need to select a primary care physician.
• You are covered for services in or out of the network, but your costs may be higher when you go out of the network.
• Referrals are not necessary and there is virtually no paperwork.
• There is no deductible for in-network care.

Personal Choice 65 PPO plans include:

• a network of more than 22,000 area physicians and specialists;
• our award-winning health resources and wellness programs;
• trained Health Coaches, available by phone 24/7/365, to help manage chronic conditions, such as asthma, diabetes, and COPD;
• coverage for routine medical exams and screenings;

• If you choose to enroll in Personal Choice 65 Rx PPO coverage:
• You will have the convenience of paying just one premium each month for both your medical and drug coverage.
• You can go to thousands of pharmacies within the network and simply present your Personal Choice 65 PPO card. Learn more about prescription drug coverage.

• 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 an answering machine.
• Members can call 1-888-718-3333 (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.

For details of covered services, copays, and deductibles for Personal Choice 65 PPO plans, see the Summary of Benefits Y0041_H3909_PC12_03 CMS Approved 09092011.

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.

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 Pending CMS Approval