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Keystone 65 HMO2022Summary of BenefitsEffective January 1, 2022 through December 31, 2022 Keystone 65 Basic Rx HMOKeystone 65 Focus Rx HMO-POSKeystone 65 Select Medical-Only HMOKeystone 65 Select Rx HMOH3952Y0041 H3952 KS 22 99146 M
This booklet gives you a summary of what we coverand what you pay. It doesn’t list every service that wecover or list every limitation or exclusion. To get acomplete list of services we cover, call us and ask for theEvidence of Coverage or go online at www.ibxmedicare.com.This Summary of Benefits booklet gives you a summary of what Keystone 65 Basic Rx HMO,Keystone 65 Focus Rx HMO-POS, Keystone 65 Select Medical-Only HMO, and Keystone 65Select Rx HMO cover and what you pay.Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, Keystone 65 SelectMedical-Only HMO, and Keystone 65 Select Rx HMO are Medicare Advantage HMO(Health Maintenance Organization) plans. With an HMO plan, members choose a familydoctor, called a primary care physician (PCP), who provides the services they need.When they need specialized care, PCPs refer members to other doctors or health careproviders within the HMO provider network. Keystone 65 Focus Rx HMO-POS has aPoint-of-Service (POS) option. "Point-of-service" means you can use providers outside theplan's network for an additional cost. Members pay less if they use doctors, hospitals,and other health care providers that belong to the plan’s network. If you choose to see adoctor or specialist out of network, you may pay a higher cost-share except in the case ofan emergency.If you want to compare our plans with other available Medicare health plans, ask the otherplan(s) for their Summary of Benefits booklet. Or, use the Medicare Plan Finder atwww.medicare.gov. If you want to know more about the coverage and costs of OriginalMedicare, look in your current “Medicare and You” handbook. View it online atwww.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227),24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.Sections of this booklet Monthly Premium and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits P rescription Drug Benefits for Keystone 65 Basic Rx, Keystone 65 Focus Rx,and Keystone 65 Select RxWho can join?To join Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, Keystone 65 SelectMedical-Only HMO, or Keystone 65 Select Rx HMO, you must be entitled to MedicarePart A, be enrolled in Medicare Part B, and live in our service area. Our service areaincludes the following counties in Pennsylvania: Bucks, Chester, Delaware, Montgomery,and Philadelphia.
Which doctors, hospitals, and pharmacies can I use?Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, Keystone 65 SelectMedical-Only HMO, and Keystone 65 Select Rx HMO have networks of doctors, hospitals,pharmacies, and other providers. Keystone 65 Basic Rx HMO, Keystone 65 SelectMedical-Only HMO, and Keystone 65 Select Rx HMO: If you use providers that are not inour networks, the plans may not pay for the services. With Keystone 65 Focus Rx HMOPOS, if you choose to see a doctor or specialist out of network, you may pay a highercost-share except in the case of an emergency.Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Keystone 65Select Rx HMO cover Part D drugs. In addition, the plans cover Part B drugs, such aschemotherapy and some other drugs administered by your provider. You can see ourcomplete plan Formulary (List of Covered Drugs) and any restrictions on our website:www.ibxmedicare.com.Keystone 65 Select Medical-Only HMO covers Part B drugs, including chemotherapyand some other drugs administered by your provider. However, this plan does not coverPart D prescription drugs.Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Keystone 65Select Rx HMO have a preferred pharmacy network; cost-sharing for drugs mayvary depending on the pharmacy you use. To view our lists of network providers andpharmacies (Provider/Pharmacy Directory), please visit www.ibxmedicare.com.1
Monthly Plan PremiumKeystone 65 Basic Rx HMOAnd You Have.Keystone 65 Basic Rx HMOIf You Live In.You Pay.Chester, Delaware, orMontgomery County 0Bucks or PhiladelphiaCounty 0Keystone 65 Focus Rx HMO-POSAnd You Have.Keystone 65 Focus Rx HMO-POSIf You Live In.You Pay.2Chester, Delaware, orMontgomery County 15Bucks or PhiladelphiaCounty 0
Keystone 65 Select Rx HMOAnd You Have.Keystone 65 Select Rx HMOIf You Live In.You Pay.Chester, Delaware, orMontgomery County 83.50Bucks or PhiladelphiaCounty 57.50Keystone 65 Select Medical-Only HMOAnd You Have.Keystone 65 Select Medical-Only HMOIf You Live In.You Pay.Chester, Delaware, orMontgomery County 49.50Bucks or PhiladelphiaCounty 34.503
Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSDeductibleThis plan does not have a deductible forcovered medical services or for PartD prescription drugs.This plan does not have a deductible forcovered medical services or for PartD prescription drugs.Maximum Out-of-Pocket 7,550 each year 6,500 each yearOur plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.Our plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.The Point-of-Service annualmaximum is 1,000.(the amounts you pay for yourpremium, Part D prescriptiondrugs, and some medicalservices do not count towardyour maximum out-of-pocket(MOOP) amount)Out-of-network cost-sharing doesNOT apply to the MOOP.Covered Medical and Hospital BenefitsKeystone 65Basic Rx HMOInpatient HospitalCoverage (1)Keystone 65Focus Rx HMO-POS 250 copayment per day for days 1through 7 per admission. 210 copayment per day for days 1through 6 per admission.You pay nothing per day for days 8and beyond per admission; 1,750maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period.You pay nothing per day for days 7and beyond per admission; 1,260maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period. 0 copaymentIn-Network: 0 copaymentOut-of-Network: 20% coinsurance Outpatient HospitalFacility (1) 350 copaymentIn-Network: 325 copaymentOut-of-Network: 20% coinsurance Observation Services 350 copayment per stay 325 copayment per stayOut-of-Network: 20% coinsuranceInpatient Hospital Stay Acute due to COVID-19diagnosis (1)Outpatient Hospital Coverage4Services with a (1) may require prior authorization.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMOThis plan does not have a deductible forcovered medical services.This plan does not have a deductible forcovered medical services or for PartD prescription drugs. 4,900 each year 4,900 each yearOur plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.Our plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 250 copayment per day for days 1through 6 per admission. 250 copayment per day for days 1through 6 per admission.You pay nothing per day for days 7and beyond per admission; 1,500maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period.You pay nothing per day for days 7and beyond per admission; 1,500maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period. 0 copayment 0 copayment 350 copayment 350 copayment 350 copayment per stay 350 copayment per stayServices with a (1) may require prior authorization.5
Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSDoctor’s Office Visits Primary Care Physician 0 copaymentIn-Network: 0 copaymentOut-of-Network: 20% coinsurance Specialist 35 copaymentIn-Network: 40 copaymentOut-of-Network: 20% coinsuranceYou pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.You pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service.Out-of-Network: 20% coinsuranceEmergency Care - coveredworldwide 90 copaymentNot waived if admitted 90 copaymentNot waived if admittedUrgently Needed Services covered worldwide 15 copayment in a retail clinicNot waived if admitted 10 copayment in a retail clinicNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 90 copaymentper visit for Worldwide UrgentCoverage Not waived if admittedIn-Network: 90 copaymentper visit for Worldwide UrgentCoverage Not waived if admitted.Out-ot-Network: Not coveredEmergency and urgently needed careservices received outside the U.S. donot count toward the MOOP.Emergency and urgently needed careservices received outside the U.S. donot count toward the MOOP. 0 copayment appliesto certain diagnostic tests (e.g. homebased sleep studies provided by a homehealth agency; diagnostic colonoscopiesthat result from a preventivecolonoscopy).In-Network: 0 copayment appliesto certain diagnostic tests (e.g. homebased sleep studies provided by a homehealth agency; diagnostic colonoscopiesthat result from a preventivecolonoscopy). 45 or 250 copaymentdepending on service 40 or 250 copaymentdepending on service 0 copayment 0 copayment 45 copayment for routineradiology services 40 copayment for routineradiology services 60 copayment 60 copaymentOut-of-network: 20% coinsurance 0 copayment with a diagnosisof breast cancer 0 copayment with a diagnosisof breast cancerPreventive Care (1)(e.g., flu vaccine, diabeticscreenings)Diagnostic Services, Laband Radiology Services,and X-rays Diagnostic RadiologyServices (1) D iagnostic procedures,tests, and lab services (1) Outpatient X-rays Therapeutic Radiology (1) Therapeutic Radiologyfor Breast Cancer6Services with a (1) may require prior authorization.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 0 copayment 0 copayment 40 copayment 40 copaymentYou pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.You pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service. 90 copaymentNot waived if admitted 90 copaymentNot waived if admitted 15 copayment in a retail clinicNot waived if admitted 15 copayment in a retail clinicNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 90 copaymentper visit for Worldwide UrgentCoverage Not waived if admitted 90 copaymentper visit for Worldwide UrgentCoverage Not waived if admittedEmergency and urgently needed careservices received outside the U.S. donot count toward MOOP.Emergency and urgently needed careservices received outside the U.S. donot count toward MOOP. 0 copayment appliesto certain diagnostic tests (e.g. homebased sleep studies provided by a homehealth agency; diagnostic colonoscopiesthat result from a preventivecolonoscopy). 0 copayment appliesto certain diagnostic tests (e.g. homebased sleep studies provided by a homehealth agency; diagnostic colonoscopiesthat result from a preventivecolonoscopy). 40 or 200 copaymentdepending on service 40 or 200 copaymentdepending on service 0 copayment 0 copayment 40 copayment for routineradiology services 40 copayment for routineradiology services 60 copayment 60 copayment 0 copayment with a diagnosisof breast cancer 0 copayment with a diagnosisof breast cancerServices with a (1) may require prior authorization.7
Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSHearing Services Hearing Exam 35 copayment forMedicare-covered hearing examsIn-Network: 40 copayment forMedicare-covered hearing examsOut-of-Network: 20% coinsurance Hearing Aid8 0 copayment for routine nonMedicare-covered hearing examsonce every year 0 copayment for routine nonMedicare-covered hearing examsonce every year 699 copayment for an advanceddigital hearing aid or 999copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; unlimited hearingaid fittings per year; and up to 2hearing aids every year, one hearingaid per ear. 699 copayment for an advanceddigital hearing aid or 999copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; unlimited hearingaid fittings per year; and up to 2hearing aids every year, one hearingaid per ear.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 40 copayment forMedicare-covered hearing exams 40 copayment forMedicare-covered hearing exams 0 copayment for routine nonMedicare-covered hearing examsonce every year 0 copayment for routine nonMedicare-covered hearing examsonce every year 499 copayment for an advanceddigital hearing aid or 799copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; unlimited hearingaid fittings per year; and up to 2 hearingaids every year, one hearing aidper ear. 499 copayment for an advanceddigital hearing aid or 799copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; unlimited hearingaid fittings per year; and up to 2 hearingaids every year, one hearing aidper ear.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.9
Keystone 65Basic Rx HMODental Services 35 copayment fornon-routine Medicare-covereddental services in a specialist officeKeystone 65Focus Rx HMO-POSIn-Network: 40 copayment fornon-routine Medicare-covereddental services in a specialist officeOut-of-Network: 20% coinsurance10 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full-mouth X-ray(panoramic) every 3 years. 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full-mouth X-ray(panoramic) every 3 years. 2,500 in-network allowanceevery year for restorative services,endodontics, periodontics,extractions, prosthodontics,other oral/maxillofacial surgery,and other services. 2,000 in-network allowanceevery year for restorative services,endodontics, periodontics,extractions, prosthodontics,other oral/maxillofacial surgery,and other services.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.Member must use in-networkUnited Concordia dental providers.Member must use in-networkUnited Concordia dental providers.Routine dental services do NOTcount toward the annual MOOP.Routine dental services do NOTcount toward the annual MOOP.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 40 copayment fornon-routine Medicare-covereddental services in a specialist office 40 copayment fornon-routine Medicare-covereddental services in a specialist office 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full-mouth X-ray(panoramic) every 3 years. 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full-mouth X-ray(panoramic) every 3 years. 2,000 in-network allowanceevery year for restorative services,endodontics, periodontics,extractions, prosthodontics,other oral/maxillofacial surgery,and other services. 2,000 in-network allowanceevery year for restorative services,endodontics, periodontics,extractions, prosthodontics,other oral/maxillofacial surgery,and other services.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.Member must use in-networkUnited Concordia dental providers.Member must use in-networkUnited Concordia dental providers.Routine dental services do NOTcount toward the annual MOOP.Routine dental services do NOTcount toward the annual MOOP.11
Keystone 65Basic Rx HMOVision Services 35 copayment forMedicare-covered eye exams todiagnose and treat diseases of theeye; 0 copayment for diabeticretinal exam; 0 copaymentfor glaucoma screening; and 0copayment for Medicare-coveredeyeglasses or contact lenses aftercataract surgery.Keystone 65Focus Rx HMO-POSIn-Network: 40 copayment forMedicare-covered eye exams todiagnose and treat diseases of theeye; 0 copayment for diabeticretinal exam; 0 copaymentfor glaucoma screening; and 0copayment for Medicare-coveredeyeglasses or contact lenses aftercataract surgery.Out-of-Network: 20% coinsurance12 0 copay for one routine eye examevery year; contact lenses or 1 pairof eyeglass frames and lenses arecovered every year. 0 copay for one routine eye examevery year; contact lenses or 1 pairof eyeglass frames and lenses arecovered every year.If eyewear is purchased from theDavis Vision Collection, the eyeglassframes and lenses are covered in full. 250 plan allowance every yearon eyewear (glasses and lenses)purchased through Visionworks; 150 plan allowance every yearfor all other eyewear (glasses andlenses) purchased through DavisVision; 150 allowance every yearfor contact lenses in lieu of routineeyewear (frames and lenses).Eyewear does not include lensoptions, such as tints, progressives,Transitions lenses, polish, andinsurance. Routine vision services(exam and eyewear) do not counttowards the annual MOOP.If eyewear is purchased from theDavis Vision Collection, the eyeglassframes and lenses are covered in full. 250 plan allowance every yearon eyewear (glasses and lenses)purchased through Visionworks; 150 plan allowance every yearfor all other eyewear (glasses andlenses) purchased through DavisVision; 150 allowance every yearfor contact lenses in lieu of routineeyewear (frames and lenses).Eyewear does not include lensoptions, such as tints, progressives,Transitions lenses, polish, andinsurance. Routine vision services(exam and eyewear) do not counttowards the annual MOOP.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 40 copayment forMedicare-covered eye exams todiagnose and treat diseases of theeye; 0 copayment for diabeticretinal exam; 0 copaymentfor glaucoma screening; and 0copayment for Medicare-coveredeyeglasses or contact lenses aftercataract surgery. 40 copayment forMedicare-covered eye exams todiagnose and treat diseases of theeye; 0 copayment for diabeticretinal exam; 0 copaymentfor glaucoma screening; and 0copayment for Medicare-coveredeyeglasses or contact lenses aftercataract surgery. 0 copay for one routine eye examevery year; contact lenses or 1 pairof eyeglass frames and lenses arecovered every year. 0 copay for one routine eye examevery year; contact lenses or 1 pairof eyeglass frames and lenses arecovered every year.If eyewear is purchased from theDavis Vision Collection, the eyeglassframes and lenses are covered in full. 250 plan allowance every yearon eyewear (glasses and lenses)purchased through Visionworks; 150 plan allowance every yearfor all other eyewear (glasses andlenses) purchased through DavisVision; 150 allowance every yearfor contact lenses in lieu of routineeyewear (frames and lenses).Eyewear does not include lensoptions, such as tints, progressives,Transitions lenses, polish, andinsurance. Routine vision services(exam and eyewear) do not counttowards the annual MOOP.If eyewear is purchased from theDavis Vision Collection, the eyeglassframes and lenses are covered in full. 250 plan allowance every yearon eyewear (glasses and lenses)purchased through Visionworks; 150 plan allowance every yearfor all other eyewear (glasses andlenses) purchased through DavisVision; 150 allowance every yearfor contact lenses in lieu of routineeyewear (frames and lenses).Eyewear does not include lensoptions, such as tints, progressives,Transitions lenses, polish, andinsurance. Routine vision services(exam and eyewear) do not counttowards the annual MOOP.13
Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSMental Health Services Inpatient Mental HealthCare (2) 250 copayment per day for days 1through 7 per admission 210 copayment per day for days 1through 6 per admissionYou pay nothing for day 8 and beyondper admissionYou pay nothing for day 7 and beyondper admission 1,750 maximum copaymentper admission 1,260 maximum copaymentper admission190-day lifetime maximum in amental health facility190-day lifetime maximum in amental health facilityOut-of-Network: 20% coinsurance 40 copaymentIn-Network: 40 copaymentOut-of-Network: 20% coinsurance 40 copaymentIn-Network: 40 copaymentOut-of-Network: 20% coinsurance 40 copaymentIn-Network: 40 copaymentOut-of-Network: 20% coinsurance 0 copayment per day for days 1through 20 0 copayment per day for days 1through 20 188 copayment per day for days 21through 100 188 copayment per day for days 21through 100100 days perbenefit period100 days perbenefit periodOut-of-Network: 20% coinsurancePhysical Therapy (1) 25 copayment 20 copaymentOut-of-Network: 20% coinsuranceAmbulance (1) 300 copayment for a one-way tripNot waived if admitted 275 copayment for a one-way tripNot waived if admittedNon-emergency ambulance servicesrequire prior authorizationNon-emergency ambulance servicesrequire prior authorizationOut-of-Network: 20% coinsuranceTransportationNot covered (offered under uniformflexibility, see page 26)Not coveredMedicare Part B Drugs (1)(Step therapy required forcertain Part B drugs)20% coinsurance for Part B drugs,such as chemotherapy drugs20% coinsurance for Part B drugs,such as chemotherapy drugsFor a description of the types ofdrugs available under Part B, seeyour Evidence of Coverage.For a description of the types ofdrugs available under Part B, seeyour Evidence of Coverage. Outpatient Therapy(Group and Individual) (2) Outpatient SubstanceAbuse Services (Groupand Individual) Partial Hospitalization (2)Skilled Nursing Facility (1)Out-of-Network: 20% coinsuranceAmbulatory SurgicalServices (1) 200 copaymentServices with a (1) may require prior authorization.14 (2) Prior authorization is required by Magellan Behavioral Health.In-Network: 200 copaymentOut-of-Network: 20% coinsurance
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 250 copayment per day for days 1through 6 per admission 250 copayment per day for days 1through 6 per admissionYou pay nothing for day 7 and beyondper admissionYou pay nothing for day 7 and beyondper admission 1,500 maximum copaymentper admission 1,500 maximum copaymentper admission190-day lifetime maximum in amental health facility190-day lifetime maximum in amental health facility 40 copayment 40 copayment 40 copayment 40 copayment 40 copayment 40 copayment 0 copayment per day for days 1through 20 0 copayment per day for days 1through 20 188 copayment per day for days 21through 100 188 copayment per day for days 21through 100100 days perbenefit period100 days perbenefit period 20 copayment 20 copayment 250 copayment for a one-way tripNot waived if admitted 250 copayment for a one-way tripNot waived if admittedNon-emergency ambulance servicesrequire prior authorizationNon-emergency ambulance servicesrequire prior authorizationNot covered (offered under uniform flexibility,see page 26)Not covered (offered under uniform flexibility,see page 26)20% coinsurance for Part B drugs,such as chemotherapy drugs20% coinsurance for Part B drugs,such as chemotherapy drugsFor a description of the types ofdrugs available under Part B, seeyour Evidence of Coverage.For a description of the types ofdrugs available under Part B, seeyour Evidence of Coverage. 200 copayment 200 copaymentServices with a (1) may require prior authorization.15
Prescription Drug Benefits (Part D)Part D Prescription Drug Benefits are available for members of Keystone 65 Basic Rx HMO,Keystone 65 Focus Rx HMO-POS, and Keystone 65 Select Rx HMO. This benefit is not available for members ofKeystone 65 Select Medical-Only HMO.Initial Coverage Stage16Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSYou pay the following until your totalyearly drug costs reach 4,430.“Total yearly drug costs” are thetotal drug costs paid by both you andour Part D plan.You pay the following until your totalyearly drug costs reach 4,430.“Total yearly drug costs” are thetotal drug costs paid by both you andour Part D plan.You may get your drugs atnetwork retail pharmacies andmail-order pharmacies.You may get your drugs atnetwork retail pharmacies andmail-order pharmacies.Cost-sharing may change dependingon the pharmacy you choose andwhen you move into each stageof your Part D benefits. You mayfill your prescriptions at either apreferred or standard pharmacy.Tier 1 and 2 prescriptions (whichinclude most generic drugs) will havelower copayments when you havethem filled at preferred pharmacies.Cost-sharing may change dependingon the pharmacy you choose andwhen you move into each stageof your Part D benefits. You mayfill your prescriptions at either apreferred or standard pharmacy.Tier 1 and 2 prescriptions (whichinclude most generic drugs) will havelower copayments when you havethem filled at preferred pharmacies.For information, please reviewthe Keystone 65 HMOEvidence of Coverage.For information, please reviewthe Keystone 65 HMOEvidence of Coverage.
Keystone 65Select Medical-Only HMOPart D prescription drugs are notavailable with this plan.Keystone 65Select Rx HMOYou pay the following until your totalyearly drug costs reach 4,430.“Total yearly drug costs” are thetotal drug costs paid by both you andour Part D plan.You may get your drugs atnetwork retail pharmacies andmail-order pharmacies.Cost-sharing may change dependingon the pharmacy you choose andwhen you move into each stageof your Part D benefits. You mayfill your prescriptions at either apreferred or standard pharmacy.Tier 1 and 2 prescriptions (whichinclude most generic drugs) will havelower copayments when you havethem filled at preferred pharmacies.For information, please reviewthe Keystone 65 HMOEvidence of Coverage.17
Prescription Drug Benefits(Part D) (cont.)Retail Cost-Sharing(what you pay at a pharmacylocation)Keystone 65Basic Rx Preferred Pharmacy 0copayment 0copayment 0copaymentStandard Pharmacy 9copayment 18copayment 27copaymentPreferred Pharmacy 10copayment 20copayment 20copaymentStandard Pharmacy 20copayment 40copayment 60copaymentPreferred Pharmacy 47copayment 94copayment 141copaymentStandard Pharmacy 47copayment 94copayment 141copaymentNot coveredNot coveredNot coveredTier 1 (Preferred Generic Drugs)Tier 2 (Generic Drugs)Tier 3 (Preferred Brand Drugs)Tier 3 (Insulin Savings Program)Preferred PharmacyStandard Pharmacy18
Keystone 65Focus Rx pply 0copayment 0copayment 9copaymentKeystone 65SelectMedical-OnlyHMOPart D prescriptiondrugs are notavailable withthis plan.Keystone 65Select Rx HMOOne-MonthSupplyTwo-MonthSupplyThree-MonthSupply 0copayment 0copayment 0copayment 0copayment 18copayment 27copayment 9copayment 18copayment 27copayment 10copayment 20copayment 20copayment 9copayment 18copayment 18copayment 20copayment 40copayment 60copayment 20copayment 40copayment 60copayment 47copayment 94copayment 141copayment 47copayment 94copayment 141copayment 47copayment 94copayment 141copayment 47copayment 94copayment 141copaymentInsulin: 35copayment*Insulin: 70copayment*Insulin: 105copayment*Insulin: 35copayment*Insulin: 70copayment*Insulin: 105copayment*Insulin: 35copayment*Insulin: 70copayment*Insulin: 105copayment*Insulin: 35copayment*Insulin: 70copayment*Insulin: 105copayment** Insulin copayment through the coverage gap for covered select insulins offered under the InsulinSavings Program.19
Prescription Drug Benefits(Part D) (cont.)Retail Cost-Sharing(what you pay at a pharmacylocation) continuedKeystone 65Basic Rx Preferred Pharmacy 100copayment 200copayment 300copaymentStandard Pharmacy 100copayment 200copayment 300copaymentPreferred Standard Tier 1 (Preferred Generic Drugs) 0copayme
our networks, the plans may not pay for the services. With Keystone 65 Focus Rx HMO-POS, if you choose to see a doctor or specialist out of network, you may pay a higher cost-share except in the case of an emergency. Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Keystone 65 Select Rx HMO cover Part D drugs.
