Plan Documents

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. Effective January 1, 2016, the hearing aid reimbursement is only available to certain Keystone 65 HMO employer group plans. All other requests must be accompanied with a paid receipt dated January 1, 2015 through December 31, 2015 in order to qualify for the reimbursement. If you have questions about how to complete this form or the Medicare hearing aid reimbursement process, please contact Customer Service at 1-800-645-3965, Monday through Friday from 8 a.m. to 6 p.m.

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 65^SM 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.

Keystone 65 HMO Influenza Vaccine Reimbursement Form
Y0041_HM_16_40418

Personal Choice 65^SM PPO Influenza Vaccine Reimbursement Form
Y0041_HM_16_40418

Download a 2016 Summary of Benefits in PDF format:

• Keystone 65 HMO Summary of Benefits Y0041_H3952_KS_16_31991 Accepted 08/31/2015
• Personal Choice 65 PPO Summary of Benefits Y0041_H3909_PC_16_31978 Accepted 08/31/2015

Call us at 1-877-393-6733 (711 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

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

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.

2016 Evidences of Coverage

• Keystone 65 Focus Rx HMO Evidence of Coverage
  Y0041_H3952_KS_16_31547 accepted 08/28/2015
• Keystone 65 Select Medical-Only HMO Evidence of Coverage
  Y0041_H3952_KS_16_31545 accepted 08/28/2015
• Keystone 65 Select Rx HMO Evidence of Coverage
  Y0041_H3952_KS_16_31546 accepted 08/28/2015
• Keystone 65 Preferred HMO Medical-Only Evidence of Coverage
  Y0041_H3952_KS_16_31544 accepted 08/28/2015
• Keystone 65 Preferred Rx HMO Evidence of Coverage
  Y0041_H3952_KS_16_31491 accepted 08/28/2015
• Personal Choice 65^SM Medical-Only PPO Evidence of Coverage
  Y0041_H3909_PC_16_32918 accepted 08/28/2015
• Personal Choice 65^SM Rx PPO Evidence of Coverage
  Y0041_H3909_PC_16_32919 accepted 08/28/2015
• Keystone 65 HMO Evidence of Coverage - Group plans only
• Personal Choice 65^SM PPO Evidence of Coverage - Group plans only
• Select Option^® PDP Evidence of Coverage - Group plans only

BlueExtra Outlines of Coverage

For details of covered services, copays, and deductibles for BlueExtra Basic, see the:

• BlueExtra Basic Outline of Coverage
• BlueExtra Basic Policy

For details of covered services, copays, and deductibles for BlueExtra Plus, see the:

• BlueExtra Plus Outline of Coverage
• BlueExtra Plus Policy

2016 Medigap Security Outlines of Coverage

• 2016 Medigap Security Individual Outline of Coverage
• 2016 Medigap Security Group Outline of Coverage

2016 Security 65 Outlines of Coverage

• 2016 Security 65 Individual Outline of Coverage

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 65^SM 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.

Change Plans online:

2016

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:

Keystone 65 HMO

2016

Keystone 65 HMO Change Form
Y0041_H3952_KS_16_31550 Approved 8/6/2015

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

Personal Choice 65

2016

Personal Choice 65 PPO Change Form
Y0041_H3909_PC_16_31551 Approved 8/6/2015

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

2016 Annual Notice of Changes

• Keystone 65 Select Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
  Y0041_H3952_KS_16_31546 Accepted 08/28/2015
  Note: This document is only applicable for former members of Keystone 65 Basic Rx HMO (Philadelphia, Bucks Counties)
• Keystone 65 Select HMO Medical-Only Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
  Y0041_H3952_KS_16_31545 Accepted 08/28/2015
• Keystone 65 Select Medical-Only HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
  Y0041_H3952_KS_16_31545 Accepted 08/28/2015
• Keystone 65 Select Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
  Y0041_H3952_KS_16_31546 Accepted 08/28/2015
• Keystone 65 Select Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
  Y0041_H3952_KS_16_31546 Accepted 08/28/2015
• Keystone 65 Preferred HMO Medical-Only Annual Notice of Changes (Philadelphia, Bucks Counties)
  Y0041_H3952_KS_16_31544 Accepted 08/28/2015
• Keystone 65 Preferred HMO Medical-Only Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
  Y0041_H3952_KS_16_31544 Accepted 08/28/2015
• Keystone 65 Preferred Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
  Y0041_H3952_KS_16_31491 Accepted 08/28/2015
• Keystone 65 Preferred Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
  Y0041_H3952_KS_16_31491 Accepted 08/28/2015
• Personal Choice 65 Rx PPO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
  Y0041_H3909_PC_16_32919 Accepted 08/28/2015
• Personal Choice 65 PPO Medical-Only Annual Notice of Changes (Philadelphia, Bucks Counties)
  Y0041_H3909_PC_16_32918 Accepted 08/28/2015
• Personal Choice 65 Rx PPO Annual Notice of Changes (Philadelphia, Bucks Counties)
  Y0041_H3909_PC_16_32919 Accepted 08/28/2015

• Keystone 65 HMO Electronic Funds Transfer (EFT) Form
  Y0041_HM_16_35708 Approved 9/28/2015
• Personal Choice 65 PPO Electronic Funds Transfer (EFT) Form
  Y0041_HM_16_35708 Approved 9/28/2015
• Select Option PDP Electronic Funds Transfer (EFT) Form
• Security 65 Electronic Funds Transfer (EFT) Form
• MedigapSecurity Electronic Funds Transfer (EFT) Form
• BlueExtra Electronic Funds Transfer (EFT) Form

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.

2016 Disenrollment Forms

Keystone 65 Focus Rx HMO Disenrollment Form
Y0041_HM_15_23302 Accepted 10/04/2014

Keystone 65 Select Medical-only HMO Disenrollment Form
Y0041_HM_15_23302 Accepted 10/04/2014

Keystone 65 Select Rx HMO Disenrollment Form
Y0041_HM_15_23302 Accepted 10/04/2014

Keystone 65 Preferred Medical-only HMO Disenrollment Form
Y0041_HM_15_23302 Accepted 10/04/2014

Keystone 65 Preferred Rx HMO Disenrollment Form
Y0041_HM_15_23302 Accepted 10/04/2014

Personal Choice 65^SM Medical-only PPO Disenrollment Form
Y0041_HM_15_23302 Accepted 10/04/2014

Personal Choice 65^SM Rx PPO Disenrollment Form
Y0041_HM_15_23302 Accepted 10/04/2014

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.

Keystone 65 Disenrollment Election Form
Y0041_HM_15_23304 Accepted 10/04/2014

Personal Choice 65 Disenrollment Election Form
Y0041_HM_15_23304 Accepted 10/04/2014

Download 2016 Grievances Information

For more information on Keystone 65 Focus Rx HMO grievances, please reference Chapter 9, Section 10 on page 179 in your EOC or click on the link below.

Keystone 65 Focus Rx HMO Grievances
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Select Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 126 in your EOC or click on the link below.

Keystone 65 Select Medical-only HMO Grievances
Y0041_H3952_KS_16_31545 accepted 08/28/2015

For more information on Keystone 65 Select Rx HMO grievances, please reference Chapter 9, Section 10 on page 182 in your EOC or click on the link below.

Keystone 65 Select Rx HMO Grievances
Y0041_H3952_KS_16_31546 accepted 08/28/2015

For more information on Keystone 65 Preferred Medical-only HMO grievances, please reference Chapter 7, Section 9 on page 120 in your EOC or click on the link below.

Keystone 65 Preferred Medical-only HMO Grievances
Y0041_H3952_KS_16_31544 accepted 08/28/2015

For more information on Keystone 65 Preferred Rx HMO grievances, please reference Chapter 9, Section 10 on page 180 in your EOC or click on the link below.

Keystone 65 Preferred Rx HMO Grievances
Y0041_H3952_KS_16_31491 accepted 08/28/2015

For more information on Personal Choice 65^SM Medical-only PPO grievances, please reference Chapter 7, Section 9 on page 132 in your EOC or click on the link below.

Personal Choice 65 Medical-only PPO Grievances
Y0041_H3909_PC_16_32918 accepted 08/28/2015

For more information on Personal Choice 65^SM Rx PPO grievances, please reference Chapter 9, Section 10 on page 190 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Grievances
Y0041_H3909_PC_16_32919 accepted 08/28/2015

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).

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.

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.

2016 Keystone 65 HMO Star Ratings
Y0041_H3952_KS_16_38294 Accepted 10/17/2015

2016 Personal Choice 65 PPO Star Ratings
Y0041_H3909_PC_16_38300 Accepted 10/17/2015