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For Members

Plan Documents


Claim Reimbursement Forms

To request a reimbursement for a hearing aid purchase, please complete the Keystone 65 HMO Hearing Aid Reimbursement Form and submit to the Independence Blue Cross Claims Department at the address listed on the form.

To request a reimbursement for a cataract glasses purchase, please complete the Cataract Glasses Reimbursement Form and submit to the Independence Blue Cross Claims Department at the address listed on the form.

To request a reimbursement as a Personal Choice 65 PPO Member for a non-network claim, please complete the Non-network claim form and submit to the Independence Blue Cross Claims Department at the address listed on the form.

As a member of Keystone 65 HMO or Personal Choice 65SM PPO, you are covered for an influenza vaccine each year. If you received your vaccine at a non-participating provider and paid out of pocket, you can use the following forms to apply for reimbursement.


Summary of Benefits

2017 Summary of Benefits

Extra help is available for those who need it most. Find out whether you qualify for low-income subsidy.




Evidence of Coverage and Outline of Coverage

The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage. It explains your benefits, premiums, and cost-sharing; conditions and limitations of coverage; and plan rules.

After you've joined the plan, you will receive the Evidence of Coverage in the mail. This is a legal document that should be kept in a safe place.

2017 Evidences of Coverage



MedigapSecurity and Security 65 Outlines of Coverage


Change Forms

Use a Change Form to move from one plan to another plan. For example, you can use a Change Form to move from Keystone 65 Preferred HMO to Keystone 65 Select HMO or Personal Choice 65 Medical-only PPO to Personal Choice 65 Rx PPO. This change can only occur during a valid Election Period.

Please keep in mind that you cannot use a change form to switch between Personal Choice 65SM PPO, a Blue Cross Medicare Advantage PPO Plan from QCC Insurance Company and Keystone 65 HMO, a Blue Cross Medicare Advantage HMO Plan from Keystone Health Plan East.

2017 Change Forms

Change Plans online:

Keystone 65 HMO Online Change Form

To get to the form using the online tool:

  1. Click the link above
  2. Select Enroll Now
  3. Enter your home Zip Code
  4. Select plan in which you would like to enroll by clicking Enroll Now
  5. Select the second link on the page: Existing Member Enrollment Form

Personal Choice 65 PPO Online Change Form

To get to the form using the online tool:

  1. Click the link above
  2. Select Enroll Now
  3. Enter your home Zip Code
  4. Select plan in which you would like to enroll by clicking Enroll Now
  5. Select the second link on the page: Existing Member Enrollment Form

Or complete and mail one of the following forms:

2017 Keystone 65 HMO

Keystone 65 HMO Change Form

Mail to:
Keystone 65 HMO
PO Box 7799
Philadelphia PA 19101-7799

2017 Personal Choice 65

Personal Choice 65 PPO Change Form

Mail to:
Personal Choice 65 PPO
PO Box 7799
Philadelphia PA 19101-7799




Disenrollment Instructions

Below are the disenrollment forms available to you. Please read these important instructions regarding requesting disenrollment from the plan.

When can I make changes to my Medicare coverage?
You can make plan changes, such as requesting disenrollment, only at certain times during the year. From October 15th through December 7th each year, anyone can make any type of change including adding or dropping Medicare prescription drug coverage. From January 1 through February 14, anyone enrolled in a Medicare Advantage Plan (except an MSA plan) has an opportunity to disenroll from that plan and return to Original Medicare. Anyone who disenrolls from a Medicare Advantage plan during this time can join a stand-alone Medicare Prescription Drug Plan during the same period. If you join a Medicare Prescription drug plan, you will be automatically disenrolled from our plan and returned to Original Medicare. Generally, you may not make changes at other times unless you meet certain special exceptions, such as if you move out of the plan's service area, want to join a plan in your area with a 5-star rating, or qualify for extra help with your prescription drug costs. If you qualify for extra help with your prescription drug costs you may enroll in, or disenroll from, a plan at any time. If you lose this extra help during the year, your opportunity to make a change continues for two months after you are notified that you no longer qualify for extra help.

What is extra help?
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won't have a coverage gap or a late enrollment penalty. Many people qualify for these savings and don't even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

When should I fill out the disenrollment request form?
You should fill out the appropriate disenrollment form during a valid election period, if you want to change to Original Medicare only and do not want Medicare prescription drug coverage.

You shouldn't fill out the appropriate disenrollment form if you are planning to enroll, or have enrolled, in another Medicare Advantage plan or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from our plan.

You shouldn't fill out the appropriate disenrollment form if you are enrolling in a Medicare prescription drug plan. Enrolling in a Medicare prescription drug plan will automatically disenroll you from the plan to Original Medicare.

Until your disenrollment date, you must keep using the plan's doctors. To avoid any unexpected expenses, you may want to contact us to make sure you've been disenrolled before you seek medical services outside of the plan's network.

How do I submit the disenrollment request?
If you want Original Medicare, as described above, you may fill out the appropriate disenrollment form during a valid election period, sign it, and send it back to us at:

Independence Blue Cross
Medicare Department
P.O. Box 7330
Philadelphia, PA 19101-8957

You can also fax the form with a readable signature and date to us at 1-888-289-3029.

You can call 1-800-MEDICARE (1-800-633-4227) for information about Medicare plans available in your area. TTY users should call 1-877-486-2048, 24 hours a day/7days a week.

What are my Medigap rights?
If you will be changing to Original Medicare, you might have a special temporary right to buy a Medigap policy, also known as Medicare supplemental insurance, even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months or if you move out of the service area, you may have this special right.

Federal law requires the protections described above. Your State may have laws that provide more Medigap protections. If you have questions about Medigap or Medigap rights in your State, you should contact your State Health Insurance Program APPRISE at 1-800-783-7067. You can also call 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week for more information about trial periods. TTY users should call 1-877-486-2048.

If you need any help, please contact the Member Help Team.

Disenrollment Forms

Typically, you may disenroll from a Medicare Advantage plan only during the Annual Enrollment Period from October 15 through December 7 of each year or during the Medicare Advantage Disenrollment Period from January 1 through February 14 of each year. There are exceptions that may allow you to disenroll from a Medicare Advantage plan outside of this period. If you are disenrolling from the plan outside of the Annual Enrollment Period or the Medicare Advantage Disenrollment Period, please also submit the following Disenrollment Election Form with your Disenrollment Form.



2017 Grievances Information



Medicare Annual Disenrollment Period (MADP)

The MADP begins on the first day of the calendar year and ends on February 14 of that same year. During the MADP, an individual enrolled in a Medicare Advantage (MA) plan may prospectively disenroll from that plan and return to Original Medicare. The effective date of the disenrollment from the MA plan is the first day of the month following the date the disenrollment request is received thus, disenrollment requests received by MA organization in January are effective February 1; those received from February 1 through February 14 are effective March 1.

During the same 45-day period, an individual using the MADP to disenroll from a MA plan is eligible for a special enrollment period (SEP) to enroll in a stand-alone Part D plan (PDP).


Appointment of a Representative

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 the Member Help Team to learn how to name your appointed representative.


Standards of Care

The Independence Blue Cross Quality Management program monitors and objectively evaluates standards and quality of care for our members.

The Quality Management program:

  • Provides tools and information to assist network providers in developing and maintaining a high standard of care;
  • Manages partnerships with network providers;
  • Monitors and evaluates the care our members receive;
  • Suggests improvements to medical policies;
  • Oversees provider credentialing;
  • Oversees various processes for hearing grievances and appeals;
  • Collects member suggestions for quality initiatives;
  • Monitors aspects of care based on the demographics of members served (i.e., age, sex, and health status);
  • Investigates and tracks potential quality-of-care concerns through the recredentialing, grievance and appeal, and peer review processes.

Member safety

We communicate member safety initiatives through newsletters and mailings to increase awareness and reduce medical and medication errors.

Member satisfaction

We take all member feedback seriously. We thoroughly investigate and aim to resolve all quality-of-care and quality-of-service issues. Any member may file a concern or complaint in writing or by calling Customer Service at the number listed on back of his or her ID card.

Continuity and coordination of care

We assess coordination and continuity of care against three criteria:

  • How well care is coordinated among medical providers who are treating the same patient;
  • How well medical and behavioral care are coordinated;
  • When a provider leaves a network, how well we ensure that his or her patients under active treatment have continuous access to care.

When a member is receiving an active course of treatment and his or her practitioner leaves the health plan, the member may be eligible for continued access to the practice for a time period mandated by specific state regulations. The health plan will notify the member in writing that his or her provider has left the network and assist the member in arranging the continuation of care and selection of a new practitioner.

Quality improvement

Information about our Quality Improvement program is available to members and providers. Upon request, we'll provide a description of our program and a report on progress. For member requests, call the Member Services number listed on the back of the ID card.

For additional details, view our Quality Management Program flyer.


Non-discrimination Notice and Multi-Language Insert

View our Non-discrimination Notice and Multi-Language Insert.


Star Ratings

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans.

Website Last Updated: 6/28/2017
Y0041_HM_17_43499i Approved 7/12/2017