Transcription
201ˆ Summaryof BenefitsEffective January 1, 201ˆ through December 31, 201ˆH3952: @) @,4@ @ "DDFQUFE
Summary of Benefits)0 -4 ˁʐ ˀˁˆʭ ( -ʐ ˁʐ ˀˁˆ5IJT CPPLMFU HJWFT ZPV B TVNNBSZ PG XIBU XF DPWFS BOE XIBU ZPV QBZ *U EPFTOhU MJTU FWFSZ TFSWJDF UIBU XF DPWFS PS MJTU FWFSZ MJNJUBUJPO PS FYDMVTJPO 5P HFU B DPNQMFUF MJTU PG TFSWJDFT XF DPWFS DBMM VT BOE BTL GPS UIF &WJEFODF PG PWFSBHF You have choices about how to get your Medicare benefitsOne choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). OriginalMedicare is run directly by the Federal government.Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Medical Only (HMO), Keystone 65 Select Rx (HMO), Keystone 65 Preferred Medical Only (HMO), and Keystone 65 Preferred Rx (HMO)).Tips for comparing your Medicare choicesThis Summary of Benefits booklet gives you a summary of what Keystone 65 'PDVT Rx (HMO), Keystone 65Select Medical Only (HMO), Keystone 65 Select Rx (HMO), Keystone 65 Preferred Medical Only (HMO),and Keystone 65 Preferred Rx (HMO) cover and what you pay.If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary ofBenefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare& You” handbook. View it online at http://www.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 in this bookletThings to Know About Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Medical Only (HMO), Keystone 65 Select Rx (HMO), Keystone 65 Preferred Medical Only (HMO), and Keystone 65 Preferred Rx (HMO)Monthly Premium, Deductible, and Limits on How Much You Pay for Covered ServicesCovered Medical and Hospital Benefits1SFTDSJQUJPO %SVH #FOFGJUT GPS Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Rx (HMO), and Keystone 65 Preferred Rx (HMO). 0QUJPOBM #FOFGJUT ZPV NVTU QBZ BO FYUSB QSFNJVN GPS UIFTF CFOFGJUT GPS Keystone 65 'PDVT 3x (HMO), Keystone 65 Select Medical Only (HMO), and Keystone 65 Select Rx (HMO).This document is available in other formats such as Braille and large print.This document may be available in a non-English language. For additional information, call us at(877) 393-6733 TTY/TDD 711.Things to Know About Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Medical Only(HMO), Keystone 65 Select Rx (HMO), Keystone 65 Preferred Medical Only (HMO), andKeystone 65 Preferred Rx (HMO)Hours of OperationFrom October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time.From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m.Eastern time.1
ummary of Benefits ummary of Benefits)0 -4 ˁʐ ˀˁˆʭ ( -ʐ ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆʭ ( -ʐ ˁʐ ˀˁˆKeystone 65 'PDVT Rx (HMO), Keystone 65 Select Medical Only (HMO), Keystone 65Select Rx (HMO), Keystone 65 Preferred Medical Only (HMO), and Keystone 65Preferred Rx (HMO) Phone Numbers and WebsiteIf you are a member of these plans, call toll-free (800) 645-3965. TTY/TDD 711.If you are not a member of these plans, call toll-free (877) 393-6733. TTY/TDD 711.0VS XFCTJUF IUUQ XXX JCYNFEJDBSF DPNOur Keystone 65 Focus Rx (HMO) and Keystone 65 Preferred Rx (HMO) You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you paydepends on the drug's tier and what stage of the benefit you have reached. Later in this document we discussthe benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage.Who can join?To join Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Medical Only (HMO), Keystone 65 Select Rx(HMO), Keystone 65 Preferred Medical Only (HMO), or Keystone 65 Preferred Rx (HMO), you must beentitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.,FZTUPOF 'PDVT 3Y ).0 Keystone 65 Select Medical Only (HMO), Keystone 65 Select Rx (HMO),Keystone 65 Preferred Medical Only (HMO), and Keystone 65 Preferred Rx (HMO): Our service areaincludes the following counties in Pennsylvania: Bucks, Chester, Delaware, Montgomery, and Philadelphia.Which doctors, hospitals, and pharmacies can I use?Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Medical Only (HMO), Keystone 65 Select Rx (HMO),Keystone 65 Preferred Medical Only (HMO), and Keystone 65 Preferred Rx (HMO) have a network ofdoctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plansmay not pay for these services.For Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Rx (HMO), and Keystone 65 Preferred Rx (HMO),you must generally use network pharmacies to fill your prescriptions for covered Part D drugs.:PV DBO TFF PVS QMBOT QSPWJEFS BOE QIBSNBDZ EJSFDUPSJFT BU PVS XFCTJUF XXX JCYNFEJDBSF DPN Or, call us and we will send you a copy of the provider/pharmacy EJSFDUPSJFT What do we cover?Like all Medicare health plans, we cover everything that Original Medicare covers - and more.Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, youmay pay more in our plan than you would in Original Medicare. For others, you may pay less.Our plan members also get more than what is covered by Original Medicare. 4PNF PG UIF FYUSB CFOFGJUT are outlined in this booklet.Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Rx (HMO) and Keystone 65 Preferred Rx (HMO): Wecover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered byyour provider. :PV DBO TFF UIF DPNQMFUF QMBO GPSNVMBSZ MJTU PG 1BSU % QSFTDSJQUJPO ESVHT BOE BOZ SFTUSJDUJPOT PO PVS XFCTJUF IUUQ XXX JCYNFEJDBSF DPN 0S DBMM VT BOE XF XJMM TFOE ZPV B DPQZ PG UIF GPSNVMBSZ Keystone 65 Select Medical Only (HMO) and Keystone 65 Preferred Medical Only (HMO) cover Part Bdrugs including chemotherapy and some drugs administered by your provider. However, these plans do notcover Part D prescription drugs.How will I determine my drug costs?Our Keystone 65 Select Rx (HMO) plans group each medication into one of five “tiers.” You will need to useyour formulary to locate what tier your drug is on to determine how much it will cost you. The amount you paydepends on the drug’s tier and what stage of the benefit you have reached. Later in this document we discuss thebenefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and CatastrophicCoverage.23
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲ4./*) ˆ ' / ' )'4 ʱ ʲ4./*) ˆ * 0. 3 ʱ ʲ ' )'4 ʱ ʲ Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services4./*) ˆ ' / 3 ʱ ʲ4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲMonthly Premium, Deductible, and Limits on How Much You Pay for Covered ServicesHow much is the monthlypremium?Please refer to the Premium /Cost-Sharing Table to find outthe premium/cost-sharing in yourarea. In addition, you must keeppaying your Medicare Part Bpremium.Please refer to the Premium /Cost-Sharing Table to find out thepremium/cost-sharing in your area.In addition, you must keep payingyour Medicare Part B premium.Please refer to the Premium /Cost-Sharing Table to find out thepremium/cost-sharing in your area.In addition, you must keep payingyour Medicare Part B premium.Please refer to the Premium /Cost-Sharing Table to find out thepremium/cost-sharing in your area.In addition, you must keep payingyour Medicare Part B premium.Please refer to the Premium /Cost-Sharing Table to find out thepremium/cost-sharing in your area.In addition, you must keep payingyour Medicare Part B premium.How much is the deductible?5IJT QMBO EPFT OPU IBWF B EFEVDUJCMF This plan does not have adeductible. QFS ZFBS GPS 1BSU % QSFTDSJQUJPO ESVHT FYDFQU GPS ESVHT MJTUFE PO 5JFS BOE 5JFS XIJDI BSF FYDMVEFE GSPN UIF EFEVDUJCMF This plan does not have adeductible.This plan does not have a deductible.Is there any limit on howmuch I will pay for my coveredservices?Yes. Like all Medicare healthplans, our plan protects you byhaving yearly limits on your outof-pocket costs for medical andhospital care.Yes. Like all Medicare healthplans, our plan protects you byhaving yearly limits on your outof-pocket costs for medical andhospital care.Yes. Like all Medicare healthplans, our plan protects you byhaving yearly limits on your outof-pocket costs for medical andhospital care.Yes. Like all Medicare healthplans, our plan protects you byhaving yearly limits on your outof-pocket costs for medical andhospital care.Your yearly limit(s) in this plan:Your yearly limit(s) in this plan:Your yearly limit(s) in this plan:Your yearly limit(s) in this plan:Yes. Like all Medicare healthplans, our plan protects you byhaving yearly limits on your outof-pocket costs for medical andhospital care.Your yearly limit(s) in this plan: GPS TFSWJDFT ZPV SFDFJWF from in-network providers. GPS TFSWJDFT ZPV SFDFJWF from in-network providers. GPS TFSWJDFT ZPV SFDFJWF from in-network providers. GPS TFSWJDFT ZPV SFDFJWF from in-network providers. GPS TFSWJDFT ZPV SFDFJWF from in-network providers.If you reach the limit on out-ofpocket costs, you keep gettingcovered hospital and medicalservices and we will pay the fullcost for the rest of the year.If you reach the limit on out-ofpocket costs, you keep gettingcovered hospital and medicalservices and we will pay the fullcost for the rest of the year.If you reach the limit on out-ofpocket costs, you keep gettingcovered hospital and medicalservices and we will pay the fullcost for the rest of the year.If you reach the limit on out-ofpocket costs, you keep gettingcovered hospital and medicalservices and we will pay the fullcost for the rest of the year.If you reach the limit on out-ofpocket costs, you keep gettingcovered hospital and medicalservices and we will pay the full costfor the rest of the year.Please note that you will stillneed to pay your monthlypremiums and cost-sharing foryour Part D prescription drugs.Please note that you will still needto pay your monthly premiums.Please note that you will still needto pay your monthly premiumsand cost-sharing for your Part Dprescription drugs.Please note that you will still needto pay your monthly premiums.Please note that you will still needto pay your monthly premiumsand cost-sharing for your Part Dprescription drugs.45
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲIs there a limit on how muchthe plan will pay?/P 5IFSF BSF OP MJNJUT PO IPX NVDI PVS QMBO XJMM QBZ 4./*) ˆ ' / ' )'4 ʱ ʲ/P 5IFSF BSF OP MJNJUT PO IPX 4./*) ˆ ' /NVDI PVS QMBO XJMM QBZ ,FZTUPOF ).0 JT BO ).0 QMBO XJUI B .FEJDBSF DPOUSBDU &OSPMMNFOU JO ,FZTUPOF ).0 EFQFOET PO DPOUSBDU SFOFXBM 64./*) ˆ ' / 3 ʱ ʲ/P 5IFSF BSF OP MJNJUT PO IPX NVDI PVS QMBO XJMM QBZ 4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲOur plan has a coverage limitevery year for certain in-networkbenefits. Contact us for theservices that apply.Our plan has a coverage limit everyyear for certain in-network benefits.Contact us for the services thatapply.,FZTUPOF ).0 JT BO ).0 QMBO XJUI B .FEJDBSF DPOUSBDU &OSPMMNFOU JO ,FZTUPOF ).0 EFQFOET PO DPOUSBDU SFOFXBM 7
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲ4./*) ˆ ' / ' )'4 ʱ ʲ 4./*) ˆ ' / 3 ʱ ʲCovered Medical and Hospital Benefits4./*) ˆ - ! -- ' )'4 ʱ ʲ 4./*) ˆ - ! -- 3 ʱ ʲCovered Medical and Hospital BenefitsNOTE:t SERVICES WITH B 1MAY REQUIRE PRIORAUTHORIZATION.t SERVICES WITH B 2 MA: REQUIRE A REFERRALFROM YOUR DOCTOR.NOTE:t SERVICES WITH B 1MAY REQUIRE PRIORAUTHORIZATION.t SERVICES WITH B 2 MA YREQUIRE A REFERRALFROM YOUR DOCTOR.Outpatient Care and ServicesNOTE:t SERVICES WITH B 1MAY REQUIRE PRIORAUTHORIZATION.t SERVICES WITH B 2 MA YREQUIRE A REFERRALFROM YOUR DOCTOR.NOTE:t SERVICES WITH B 1MAY REQUIRE PRIORAUTHORIZATION.t SERVICES WITH B 2 MAYREQUIRE A REFERRALFROM YOUR DOCTOR.NOTE:t SERVICES WITH B 1MAY REQUIRE PRIORAUTHORIZATION.t SERVICES WITH B 2 MA YREQUIRE A REFERRALFROM YOUR DOCTOR.Outpatient Care and ServicesAcupunctureNot coveredNot coveredNot coveredNot coveredNot coveredAmbulance1 5 copay copay 0 copay 100 copay 100 copayChiropractic Care2Manipulation of the spine toDPSSFDU B TVCMVYBUJPO XIFO PS more of the bones of your spinemove out of position): 20 copayManipulation of the spine toDPSSFDU B TVCMVYBUJPO XIFO PS more of the bones of your spinemove out of position): 20 copayManipulation of the spine toDPSSFDU B TVCMVYBUJPO XIFO PS more of the bones of your spinemove out of position): 20 copayManipulation of the spine toDPSSFDU B TVCMVYBUJPO XIFO PS more of the bones of your spinemove out of position): 20 copayManipulation of the spine to correctB TVCMVYBUJPO XIFO PS NPSF PG the bones of your spine move out ofposition): 20 copay3PVUJOF DIJSPQSBDUJD WJTJU GPS VQ UP FWFSZ ZFBS ùù DPQBZ3PVUJOF DIJSPQSBDUJD WJTJU GPS VQ UP FWFSZ ZFBS ùù DPQBZ83PVUJOF DIJSPQSBDUJD WJTJU GPS VQ UP FWFSZ ZFBS ùù DPQBZ4./*) ˆ ' / 3 ʱ ʲ3PVUJOF DIJSPQSBDUJD WJTJU GPS VQ UP FWFSZ ZFBS ùù DPQBZ93PVUJOF DIJSPQSBDUJD WJTJU GPS VQ UP FWFSZ ZFBS ùù DPQBZ
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲDental Services2Diabetes Supplies and Services1Limited dental services (this doesnot include services in connectionwith care, treatment, filling,removal, or replacement ofteeth): 0- copay, dependingon the service4./*) ˆ ' / ' )'4 ʱ ʲLimited dental services (this does/connectionnot4./*)include ˆ services' inwith care, treatment, filling,removal, or replacement of teeth): 0-45 copay, depending on theservice4./*) ˆ ' / 3 ʱ ʲLimited dental services (this doesnot include services in connectionwith care, treatment, filling,removal, or replacement of teeth): 0-45 copay, depending on theservice4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲLimited dental services (this doesnot include services in connectionwith care, treatment, filling,removal, or replacement of teeth): 0-40 copay, depending on theserviceLimited dental services (this doesnot include services in connectionwith care, treatment, filling,removal, or replacement of teeth): 0-40 copay, depending on theserviceDental services: 20 copay for asingle office visit that includes:Dental services: 20 copay for asingle office visit that includes: MFBOJOH GPS VQ UP FWFSZ TJY months) MFBOJOH GPS VQ UP FWFSZ TJY months) SBM FYBN GPS VQ UP FWFSZ TJY0months) SBM FYBN GPS VQ UP FWFSZ TJY0months)Diabetes monitoring supplies:You pay nothingDiabetes monitoring supplies:You pay nothingDiabetes monitoring supplies:You pay nothingDiabetes monitoring supplies:You pay nothingDiabetes monitoring supplies:You pay nothingDiabetes self-managementtraining:Diabetes self-managementtraining:Diabetes self-managementtraining:Diabetes self-managementtraining:Diabetes self-managementtraining:You pay nothingYou pay nothingYou pay nothingYou pay nothingYou pay nothingTherapeutic shoes or inserts:Therapeutic shoes or inserts:Therapeutic shoes or inserts:Therapeutic shoes or inserts:Therapeutic shoes or inserts:You pay nothingYou pay nothingYou pay nothingYou pay nothingYou pay nothing1011
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲDiagnostic Tests, Lab andRadiology Services, andX-Rays PTUT GPS UIFTF TFSWJDFT NBZ WBSZ CBTFE PO QMBDF PG TFSWJDF 1,2Doctor’s Office Visits 24./*) ˆ ' / ' )'4 ʱ ʲ4./*) ˆ ' / 3 ʱ ʲ4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲDiagnostic radiology services(such as MRIs, CT scans): 40-125 copay, depending on theserviceDiagnostic radiology services(such as MRIs, CT scans): 40- 125 copay, depending on theserviceDiagnostic radiology services(such as MRIs, CT scans): - copay, depending onthe serviceDiagnostic radiology services4./*) ˆ CT' scans):/(suchas MRIs, 50-1 copay, depending onthe serviceDiagnostic tests andprocedures:Diagnostic tests andprocedures:Diagnostic tests andprocedures:Diagnostic tests andprocedures:Diagnostic tests andprocedures:You pay nothingYou pay nothingYou pay nothingYou pay nothingYou pay nothingLab services:Lab services:Lab services:Lab services:You pay nothingYou pay nothingYou pay nothingYou pay nothingLab services:You pay nothingOutpatient X-rays: 0 copayOutpatient X-rays: 50 copayOutpatient X-rays: copayOutpatient X-rays: 40 copayOutpatient X-rays: 40 copayTherapeutic radiology services(such as radiation treatmentfor cancer): DPQBZTherapeutic radiology services(such as radiation treatment forcancer): 60 copayTherapeutic radiology services Therapeutic radiology services(such as radiation treatment for (such as radiation treatment forcancer): 60 copaycancer): 60 copayTherapeutic radiology services(such as radiation treatment forcancer): 60 copayPrimary care physician visit:Primary care physician visit:Primary care physician visit:Primary care physician visit:Primary care physician visit: 0 copay 20 copay 20 copay copay copay Specialist visit:Specialist visit:Specialist visit:Specialist visit:Specialist visit: 45 copay 45 copay 40 copay 40 copay copayDiagnostic radiology services(such as MRIs, CT scans): 50- copay, depending on theserviceDurable MedicalEquipment (wheelchairs,oxygen, etc.) 0% of the cost 20% of the cost20% of the cost 20% of the cost EFQFOEJOH PO UIF FRVJQNFOU 20% of the cost EFQFOEJOH PO UIF FRVJQNFOU Emergency Care 5 copay 5 copay 5 copay 5 copay 5 copayFoot Care (podiatry services) 'PPU FYBNT BOE USFBUNFOU JG you have diabetes-related nervedamage and/or meet certainconditions: 0 copay 'PPU FYBNT BOE USFBUNFOU JG you have diabetes-related nervedamage and/or meet certainconditions: 45 copay'PPU FYBNT BOE USFBUNFOU JG you have diabetes-related nervedamage and/or meet certainconditions: 45 copay'PPU FYBNT BOE USFBUNFOU JG you have diabetes-related nervedamage and/or meet certainconditions: 40 copay'PPU FYBNT BOE USFBUNFOU JG ZPV have diabetes-related nerve damageand/or meet certain conditions: 40copay3PVUJOF GPPU DBSF GPS VQ UP WJTJU T FWFSZ ZFBS ùù DPQBZ3PVUJOF GPPU DBSF GPS VQ UP WJTJU T FWFSZ ZFBS ùù DPQBZ3PVUJOF GPPU DBSF GPS VQ UP WJTJU T FWFSZ ZFBS ùù DPQBZ3PVUJOF GPPU DBSF GPS VQ UP WJTJU T FWFSZ ZFBS ùù DPQBZ3PVUJOF GPPU DBSF GPS VQ UP WJTJU T FWFSZ ZFBS ùù DPQBZ1213
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲHearing Services2Home Health Care14./*) ˆ ' / ' )'4 ʱ ʲ4./*) ˆ ' / 3 ʱ ʲ4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲ&YBN UP EJBHOPTF BOE USFBU hearing and balance issues:&YBN UP EJBHOPTF BOE USFBU 4./*)' /hearingand ˆ balanceissues:&YBN UP EJBHOPTF BOE USFBU hearing and balance issues:&YBN UP EJBHOPTF BOE USFBU hearing and balance issues:&YBN UP EJBHOPTF BOE USFBU IFBSJOH and balance issues: 0 copay 45 copay 45 copay 40 copay 40 copay3PVUJOF IFBSJOH FYBN GPS VQ UP every three years):3PVUJOF IFBSJOH FYBN GPS VQ UP every three years): 40 copay 40 copayHearing aid fitting/evaluation(for up to 2 every year):Hearing aid fitting/evaluation(for up to 2 every years):You pay nothing14You pay nothingYou pay nothing DPQBZ DPQBZHearing aid DPQBZ GPS FBDI IFBSJOH BJE EFQFOEJOH PO UIF UZQF)FBSJOH BJE DPQBZ GPS FBDI IFBSJOH BJE EFQFOEJOH PO UIF UZQFYou pay nothingYou pay nothing15
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲMental Health Care1Inpatient visit:4./*) ˆ ' / ' )'4 ʱ ʲ4./*) ˆ ' / 3 ʱ ʲ4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲInpatient visit:4./*) ˆ ' /Our plan covers up to 190 days in alifetime for inpatient mental healthcare in a psychiatric hospital.The inpatient hospital care limitdoes not apply to inpatient mentalservices provided in a generalhospital.Inpatient visit:Inpatient visit:Inpatient visit:Our plan covers up to 190 daysin a lifetime for inpatient mentalhealth care in a psychiatrichospital. The inpatient hospitalcare limit does not apply toinpatient mental services providedin a general hospital.Our plan covers up to 190 days in alifetime for inpatient mental healthcare in a psychiatric hospital.The inpatient hospital care limitdoes not apply to inpatient mentalservices provided in a generalhospital.Our plan covers up to 190 days in alifetime for inpatient mental healthcare in a psychiatric hospital.The inpatient hospital care limitdoes not apply to inpatient mentalservices provided in a generalhospital.Our plan covers up to 190 days in alifetime for inpatient mental healthcare in a psychiatric hospital. Theinpatient hospital care limit does notapply to inpatient mental servicesprovided in a general hospital.Our plan covers 90 days for aninpatient hospital stay.Our plan covers 90 days for aninpatient hospital stay.Our plan covers 90 days for aninpatient hospital stay.Our plan covers 90 days for aninpatient hospital stay.Our plan covers 90 days for aninpatient hospital stay.Our plan also covers 60 “lifetimeSFTFSWF EBZT w 5IFTF BSF iFYUSBw days that we cover. If your hospitalstay is longer than 90 days, youDBO VTF UIFTF FYUSB EBZT #VU PODF ZPV IBWF VTFE VQ UIFTF FYUSB 60 days, your inpatient hospitalcoverage will be limited to 90days.Our plan also covers 60 “lifetimeSFTFSWF EBZT w 5IFTF BSF iFYUSBw days that we cover. If your hospitalstay is longer than 90 days, youDBO VTF UIFTF FYUSB EBZT #VU PODF ZPV IBWF VTFE VQ UIFTF FYUSB 60 days, your inpatient hospitalcoverage will be limited to 90 days.Our plan also covers 60 “lifetimeSFTFSWF EBZT w 5IFTF BSF iFYUSBw days that we cover. If your hospitalstay is longer than 90 days, youDBO VTF UIFTF FYUSB EBZT #VU PODF ZPV IBWF VTFE VQ UIFTF FYUSB 60 days, your inpatient hospitalcoverage will be limited to 90 days.Our plan also covers 60 “lifetimeSFTFSWF EBZT w 5IFTF BSF iFYUSBw days that we cover. If your hospitalstay is longer than 90 days, youDBO VTF UIFTF FYUSB EBZT #VU PODF ZPV IBWF VTFE VQ UIFTF FYUSB 60 days, your inpatient hospitalcoverage will be limited to 90 days.Our plan also covers 60 “lifetimeSFTFSWF EBZT w 5IFTF BSF iFYUSBw days that we cover. If your hospitalstay is longer than 90 days, you canVTF UIFTF FYUSB EBZT #VU PODF ZPV IBWF VTFE VQ UIFTF FYUSB EBZT your inpatient hospital coverage willbe limited to 90 days. DPQBZ QFS EBZ GPS EBZT through DPQBZ QFS EBZ GPS EBZT through 7 DPQBZ QFS EBZ GPS EBZT through 7 DPQBZ QFS EBZ GPS EBZT through 7 DPQBZ QFS EBZ GPS EBZT through 7 PV QBZ OPUIJOH QFS EBZ GPS EBZT:8 through 90 PV QBZ OPUIJOH QFS EBZ GPS EBZT:8 through 90 :PV QBZ OPUIJOH QFS EBZ GPS EBZT8 through 90 PV QBZ OPUIJOH QFS EBZ GPS EBZT:8 through 90 PV QBZ OPUIJOH QFS EBZ GPS EBZT : through 90Outpatient group therapy visit:Outpatient group therapy visit:Outpatient group therapy visit:Outpatient group therapy visit:Outpatient group therapy visit: 40 copay 40 copay 40 copay 40 copay 40 copayOutpatient individual therapy visit: 40 copayOutpatient individual therapy visit: 40 copayOutpatient individual therapy visit: 40 copayOutpatient individual therapy visit: 40 copayOutpatient individual therapy visit: 40 copay1617
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲOutpatient Rehabilitation2Outpatient Substance AbuseOutpatient Surgery1Over-the-Counter Items4./*) ˆ ' / ' )'4 ʱ ʲ4./*) ˆ ' / 3 ʱ ʲ4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲCardiac (heart) rehab services (forB NBYJNVN PG POF IPVS TFTTJPOT per day for up to 36 sessions up to36 weeks): copayCardiac (heart) rehab services (for4./*) ˆ ' /B NBYJNVN PG POF IPVS TFTTJPOT per day for up to 36 sessions up to36 weeks): copayCardiac (heart) rehab services (forB NBYJNVN PG POF IPVS TFTTJPOT per day for up to 36 sessions up to36 weeks): 5 copayCardiac (heart) rehab services (forB NBYJNVN PG POF IPVS TFTTJPOT per day for up to 36 sessions up to36 weeks): copayCardiac (heart) rehab services (forB NBYJNVN PG POF IPVS TFTTJPOT per day for up to 36 sessions up to36 weeks): copayOccupational therapy visit:Occupational therapy visit:Occupational therapy visit:Occupational therapy visit:Occupational therapy visit: 40 copay 40 copay 40 copay 40 copay 40 copayPhysical therapy and speech andlanguage therapy visit: 40 copayPhysical therapy and speech andlanguage therapy visit: 40 copayPhysical therapy and speech andlanguage therapy visit: 40 copayPhysical therapy and speech andlanguage therapy visit: 40 copayPhysical therapy and speech andlanguage therapy visit: 40 copayGroup therapy visit: 40 copayGroup therapy visit: 40 copayGroup therapy visit: 40 copayGroup therapy visit: 40 copayGroup therapy visit: 40 copayIndividual therapy visit: 40 copayIndividual therapy visit: 40 copayIndividual therapy visit: 40 copayIndividual therapy visit: 40 copayIndividual therapy visit: 40 copayAmbulatory surgical center:Ambulatory surgical center:Ambulatory surgical center:Ambulatory surgical center:Ambulatory surgical center: 150 copayOutpatient hospital: copay 150 copay 150 copay 125 copay 125 copayOutpatient hospital: 400 copayOutpatient hospital: 400 copayOutpatient hospital: 400 copayOutpatient hospital: 400 copayNot CoveredNot CoveredNot CoveredNot CoveredNot Covered1819
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲ4./*) ˆ ' / ' )'4 ʱ ʲ4./*) ˆ ' / 3 ʱ ʲ4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲProsthetic devices: 20% of thecost4./*) ˆ ' /Prosthetic devices: 20% of thecostProsthetic devices: 20% of thecostRelated medical supplies: 0% of the costRelated medical supplies:Related medical supplies:Related medical supplies:20% of the cost20% of the cost20% of the cost1SPTUIFUJD EFWJDFT PG UIF DPTU3FMBUFE NFEJDBM TVQQMJFT PG UIF DPTURenal Dialysis20% of the cost20% of the cost20% of the cost20% of the cost20% of the costTransportationNot coveredNot coveredNot coveredNot coveredNot coveredUrgentMZ /FFEFE 4FSWJDFT 0- 0 copay, depending onthe service 20-45 copay, depending on theservice 20-45 copay, depending on theservice -40 copay, depending on theservice -40 copay, depending on theserviceVision Services2&YBN UP EJBHOPTF BOE USFBU diseases and conditions of theeye (including yearly glaucomascreening): 0- 0 copay,depending on the service&YBN UP EJBHOPTF BOE USFBU diseases and conditions of theeye (including yearly glaucomascreening): 0-45 copay,depending on the service&YBN UP EJBHOPTF BOE USFBU diseases and conditions of theeye (including yearly glaucomascreening): 0-45 copay,depending on the service&YBN UP EJBHOPTF BOE USFBU diseases and conditions of theeye (including yearly glaucomascreening): 0-40 copay,depending on the service&YBN UP EJBHOPTF BOE USFBU EJTFBTFT and conditions of theeye (including yearly glaucomascreening): 0-40 copay,depending on the serviceEyeglasses or contact lensesafter cataract surgery: DPQBZEyeglasses or contact lenses aftercataract surgery: DPQBZEyeglasses or contact lenses aftercataract surgery: DPQBZ3PVUJOF FZF FYBN GPS VQ UP every two years): 40 copayContact lenses (for up to 1 everytwo years): DPQBZ3PVUJOF FZF FYBN GPS VQ UP FWFSZ two years): 40 copayContact lenses (for up to 1 everytwo years): DPQBZ&ZFHMBTTFT GSBNFT BOE MFOTFT GPS VQ UP FWFSZ UXP ZFBST DPQBZ&ZFHMBTTFT GSBNFT BOE MFOTFT GPS VQ UP FWFSZ UXP ZFBST DPQBZEyeglasses or contact lenses aftercataract surgery: DPQBZEyeglasses or contact lenses aftercataract surgery: DPQBZ0VS QMBO QBZT VQ UP FWFSZ UXP ZFBST GPS DPOUBDU MFOTFT BOE FZFHMBTTFT GSBNFT BOE MFOTFT 0VS QMBO QBZT VQ UP FWFSZ UXP ZFBST GPS DPOUBDU MFOTFT BOE FZFHMBTTFT GSBNFT BOE MFOTFT Prosthetic Devices (braces,artificial limbs, etc.) Prosthetic devices: 0% ofthe cost2021
Summary of Benefits Summary of Benefits )0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ)0 -4 ˁʐ ˀˁˆ ʭ ( - ˁʐ ˀˁˆ4./*) ˆ * 0. 3 ʱ ʲPreventive CareYou pay nothingOur plan covers manypreventive services, including:4./*) ˆ ' / ' )'4 ʱ ʲYou pay nothing4./*) ˆ many' /Ourplan coverspreventive services, including:4./*) ˆ - ! -- ' )'4 ʱ ʲ4./*) ˆ - ! -- 3 ʱ ʲYou pay nothingYou pay nothingYou pay nothingOur plan covers manypreventive services, including:Our plan covers manypreventive services, including:Our plan covers many preventiveservices, including:4./*) ˆ ' / 3 ʱ ʲ CEPNJOBM BPSUJD BOFVSZTN"screening CEPNJOBM BPSUJD BOFVSZTN"screening" CEPNJOBM BPSUJD BOFVSZTNscreening CEPNJOBM BPSUJD BOFVSZTN"screening CEPNJOBM BPSUJD BOFVSZTN"screening"MDPIPM NJTVTF DPVOTFMJOH"MDPIPM NJTVTF DPVOTFMJOH"MDPIPM NJTVTF DPVOTFMJOH"MDPIPM NJTVTF DPVOTFMJOH"MDPIPM NJTVTF DPVOTFMJOH#POF NBTT NFBTVSFNFOU#POF NBTT NFBTVSFNFOU#POF NBTT NFBTVSFNFOU#POF NBTT NFBTVSFNFOU#POF NBTT NFBTVSFNF
Keystone 65 'PDVT Rx (HMO), Keystone 65 Select Medical Only (HMO), Keystone 65 Select Rx (HMO), Keystone 65 Preferred Medical Only (HMO), and Keystone 65 Preferred Rx (HMO) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plans may not pay for these services.
