Transcription
Keystone 65 HMO2017Personal Choice 65 PPOSMSummary of BenefitsSelect Option PDPEffective January 1, 2017 through December 31, 2017Blue ExtraSM Keystone 65 Focus Rx HMOKeystone 65 Select Medical-only HMOKeystone 65 Select Rx HMOKeystone 65 Preferred Medical-only HMOKeystone 65 Preferred Rx HMOH3952KS7536 (7/16)MedigapSecurityY0041 H3952 KS 17 43189 Accepted (8/26/2016)
This booklet gives you a summary of what we cover and what you pay.It doesn’t list every service that we cover or list every limitation orexclusion. To get a complete list of services we cover, call us and askfor the Evidence of Coverage.Monthly Plan PremiumKeystone 65 Preferred HMO:And You Have.Keystone 65 PreferredMedical-only HMOKeystone 65Preferred Rx HMOThis Summary of Benefits booklet gives you a summary of what Keystone 65 Focus Rx HMO, Keystone65 Select Medical-only HMO, Keystone 65 Select Rx HMO, Keystone 65 Preferred Medical-only HMO, andKeystone 65 Preferred Rx HMO cover and what you pay.If You Live In.If you want to compare our plans with other available Medicare health plans, ask the other plan(s) for theirSummary of Benefits booklet. Or, use the Medicare Plan Finder at www.medicare.gov.Chester, Delaware, orMontgomery County 219 287If you want to know more about the coverage and costs of Original Medicare, look in your current“Medicare and You” handbook. View it online at www.medicare.gov or get a copy by calling1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users shouldcall 1-877-486-2048.Bucks or PhiladelphiaCounty 173 227Sections of this bookletKeystone 65 Select HMO: Monthly Premium, Deductible, Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits for Keystone 65 Focus Rx HMO, Keystone 65 Select Rx HMO,and Keystone 65 Preferred Rx HMO Optional Supplemental Benefits (Choice Program) for Keystone 65 Focus Rx HMO,Keystone 65 Select Medical-only HMO, and Keystone 65 Select Rx HMO. You must payan extra premium for these benefits.Who can join?To join Keystone 65 Focus 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, you must be entitled toMedicare Part A, be enrolled in Medicare Part B, and live in our service area.Our service area includes the following counties in Pennsylvania: Bucks, Chester, Delaware, Montgomery,and Philadelphia.Which doctors, hospitals, and pharmacies can I use?Keystone 65 Focus 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 plansmay not pay for these services. These plans also have a preferred pharmacy network; cost-sharing for drugsmay vary depending on the pharmacy. To view our Provider/Pharmacy directory to find providers in yourplan’s network or preferred pharmacies, please visit www.ibxmedicare.com.Keystone 65 Focus Rx HMO, Keystone 65 Select Rx HMO, and Keystone 65 Preferred Rx HMO coverPart D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administeredby your provider. You can see our complete plan Formulary (List of Covered Drugs) and any restrictionson our website, www.ibxmedicare.com.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 donot cover Part D prescription drugs.You Pay.You must continue to pay your Medicare Part B premium.And You Have.If You Live In.Keystone 65Select Medicalonly HMOKeystone 65Select Rx HMOKeystone 65Select Medicalonly HMOwith ChoiceKeystone 65Select Rx HMOwith ChoiceYou Pay.Chester, Delaware, orMontgomery County 51 89 57 95Bucks or PhiladelphiaCounty 32 56 38 62You must continue to pay your Medicare Part B premium.Keystone 65 Focus Rx HMO:And You Have.Keystone 65 Focus Rx HMOIf You Live In.Keystone 65 Focus Rx HMOwith ChoiceYou Pay.Chester, Delaware, orMontgomery County 30 36Bucks or PhiladelphiaCounty 0 6You must continue to pay your Medicare Part B premium.23
Keystone 65Focus Rx HMOKeystone 65 SelectMedical-only HMOKeystone 65Select Rx HMOKeystone 65Preferred Rx HMODeductibleThis plan does not havea deductible for coveredmedical servicesThis plan does not havea deductible for coveredmedical services 350 yearly deductible for Part Dprescription drugs in Tier 3,Tier 4, and Tier 5This plan does not havea deductible for coveredmedical servicesThis plan does not havea deductible for coveredmedical servicesMaximum Out-of-Pocket(the amounts you pay forPart D prescription drugsand some services donot count towards yourmaximum out-of-pocket) 6,700 each year 5,500 each year 5,500 each year 4,000 each year 4,000 each yearOur plan has a coverage limitevery year for certain in-networkbenefits. Contact us for theservices that apply.Our plan has a coverage limitevery year for certain in-networkbenefits. Contact us for theservices that apply.Our plan has a coverage limitevery year for certain in-networkbenefits. Contact us for theservices that apply.Our plan has a coverage limitevery year for certain in-networkbenefits. Contact us for theservices that apply.Our plan has a coverage limitevery year for certain in-networkbenefits. Contact us for theservices that apply.Covered Medical and Hospital BenefitsInpatient HospitalCare (1)Covered Medical and Hospital Benefits 170 copayment per day for days1 through 6 per admission 300 copayment per day for days1 through 6 per admission 300 copayment per day for days1 through 6 per admission 240 copayment per day for days1 through 6 per admission 240 copayment per day for days1 through 6 per admissionYou pay nothing per day for days7 and beyond per admissionYou pay nothing per day for days7 and beyond per admissionYou pay nothing per day for days7 and beyond per admissionYou pay nothing per day for days7 and beyond per admissionYou pay nothing per day for days7 and beyond per admission 1,020 maximum per admission 1,800 maximum per admission 1,800 maximum per admission 1,440 maximum per admission 1,440 maximum per admissionUnlimited days per benefit periodUnlimited days per benefit periodUnlimited days per benefit periodUnlimited days per benefit periodUnlimited days per benefit period 10 copayment 20 copayment 20 copayment 5 copayment 5 copayment 40 copayment 45 copayment 45 copayment 40 copayment 40 copaymentPreventive CareYou pay nothing. Please refer tothe Evidence of Coverage for acomplete listing of services. Anyadditional preventive servicesapproved by Medicare during thecontract year will be covered.You pay nothing. Please refer tothe Evidence of Coverage for acomplete listing of services. Anyadditional preventive servicesapproved by Medicare during thecontract year will be covered.You pay nothing. Please refer tothe Evidence of Coverage for acomplete listing of services. Anyadditional preventive servicesapproved by Medicare during thecontract year will be covered.You pay nothing. Please refer tothe Evidence of Coverage for acomplete listing of services. Anyadditional preventive servicesapproved by Medicare during thecontract year will be covered.You pay nothing. Please refer tothe Evidence of Coverage for acomplete listing of services. Anyadditional preventive servicesapproved by Medicare during thecontract year will be covered.Emergency Care 75 copayment 75 copayment 75 copayment 75 copayment 75 copaymentCovered worldwideCovered worldwideCovered worldwideCovered worldwideCovered worldwide 10 copayment for retail clinic 20 copayment for urgentcare center 20 copayment for retail clinic 30 copayment for urgentcare center 20 copayment for retail clinic 30 copayment for urgentcare center 5 copayment for retail clinic 20 copayment for urgentcare center 5 copayment for retail clinic 20 copayment for urgentcare centerCovered worldwideCovered worldwideCovered worldwideCovered worldwideCovered worldwide 75 copayment outside of U.S. 75 copayment outside of U.S. 75 copayment outside of U.S. 75 copayment outside of U.S. 75 copayment outside of U.S.Doctor’s Office Visits Primary CarePhysician Specialist (2)Urgently Needed Services4Keystone 65 PreferredMedical-only HMOServices with a (1) may require prior authorization.Services with a (2) may require a referral from your doctor.5
Keystone 65Focus Rx HMOKeystone 65 SelectMedical-only HMOKeystone 65Select Rx HMOKeystone 65 PreferredMedical-only HMOKeystone 65Preferred Rx HMOOutpatient DiagnosticServices(1), Lab andRadiology Services(1),and X-rays (1,2) Diagnostic RadiologyServices 45 - 200 copaymentdepending on service 75 - 200 copayment dependingon service 75 - 200 copayment dependingon service 40 - 125 copayment dependingon service 40 - 125 copayment dependingon service Lab ServicesYou pay nothingYou pay nothingYou pay nothingYou pay nothingYou pay nothing Diagnostic Tests andProceduresYou pay nothingYou pay nothingYou pay nothingYou pay nothingYou pay nothing Outpatient X-rays 45 copayment 75 copayment 75 copayment 40 copayment 40 copayment 40 copayment for Medicarecovered hearing exams 45 copayment for Medicarecovered hearing exams 45 copayment for Medicarecovered hearing exams 40 copayment for Medicarecovered hearing exams 40 copayment for Medicarecovered hearing exams 40 copayment for routine(non-Medicare-covered hearingexams) 40 copayment for routine(non-Medicare-covered hearingexamsHearing Services (2) Hearing Exam Hearing AidDental Services (2)Hearing aids and routine(non-Medicare-covered)hearing exams are availablewith the Choice ProgramHearing aids and routine(non-Medicare-covered)hearing exams are availablewith the Choice ProgramHearing aids and routine(non-Medicare-covered)hearing exams are availablewith the Choice Program 699 - 999 copayment forhearing aids 699 - 999 copayment forhearing aids 40 copayment for non-routineMedicare-covered dental servicesin a specialist office 45 copayment for non-routineMedicare-covered dental servicesin a specialist office 45 copayment for non-routineMedicare-covered dental servicesin a specialist office 40 copayment for non-routineMedicare-covered dental servicesin a specialist office 40 copayment for non-routineMedicare-covered dental servicesin a specialist office 0 copayment for non-routineMedicare-covered dental servicesin an inpatient facility 0 copayment for non-routineMedicare-covered dental servicesin an inpatient facility 0 copayment for non-routineMedicare-covered dental servicesin an inpatient facility 0 copayment for non-routineMedicare-covered dental servicesin an inpatient facility 0 copayment for non-routineMedicare-covered dental servicesin an inpatient facilityRoutine dental services —cleanings and oral exams —are available with theChoice ProgramRoutine dental services —cleanings and oral exams —are available with theChoice ProgramRoutine dental services —cleanings and oral exams —are available with theChoice Program 20 copayment for routine dentalservices — cleanings and oralexams (1 every 6 months) 20 copayment for routine dentalservices — cleanings and oralexams (1 every 6 months)Services with a (1) may require prior authorization.Services with a (2) may require a referral from your doctor.67
Keystone 65Focus Rx HMOVision ServicesKeystone 65 SelectMedical-only HMOKeystone 65Select Rx HMOKeystone 65 PreferredMedical-only HMOKeystone 65Preferred Rx HMO 0 - 40 copayment forMedicare-covered eye exams todiagnose and treat diseases ofthe eye 0 - 45 copayment forMedicare-covered eye exams todiagnose and treat diseases ofthe eye 0 - 45 copayment forMedicare-covered eye exams todiagnose and treat diseases ofthe eye 0 - 40 copayment forMedicare-covered eye exams todiagnose and treat diseases ofthe eye 0 - 40 copayment forMedicare-covered eye exams todiagnose and treat diseases ofthe eye 0 copayment for eyeglasses orcontact lenses after cataractsurgery. Coverage for a pair ofeyeglasses will include theallowance for a standard frameand lenses. A deluxe frame and/or progressive lens will be paid upto the allowance for the standardframe and/or lens. 0 copayment for eyeglasses orcontact lenses after cataractsurgery. Coverage for a pair ofeyeglasses will include theallowance for a standard frameand lenses. A deluxe frame and/or progressive lens will be paid upto the allowance for the standardframe and/or lens. 0 copayment for eyeglassesor contact lenses after cataractsurgery. Coverage for a pair ofeyeglasses will include theallowance for a standard frameand lenses. A deluxe frame and/or progressive lens will be paid upto the allowance for the standardframe and/or lens. 0 copayment for eyeglasses orcontact lenses after cataractsurgery. Coverage for a pair ofeyeglasses will include theallowance for a standard frameand lenses. A deluxe frame and/or progressive lens will be paid upto the allowance for the standardframe and/or lens. 0 copayment for eyeglassesor contact lenses after cataractsurgery. Coverage for a pair ofeyeglasses will include theallowance for a standard frameand lenses. A deluxe frame and/or progressive lens will be paid upto the allowance for the standardframe and/or lens.Routine (non-Medicare-covered)eye exams and eyewear areavailable with the Choice ProgramRoutine (non-Medicare-covered)eye exams and eyewear areavailable with the Choice ProgramRoutine (non-Medicare-covered)eye exams and eyewear areavailable with the Choice Program 40 copayment for routine(non-Medicare-covered) eyeexams one every two years 40 copayment for routine(non-Medicare-covered) eyeexams one every two yearsCovered up to 100 for eyewearevery two yearsCovered up to 100 for eyewearevery two yearsMental Health Services (1)(including inpatient) Inpatient MentalHealth Care 170 copayment per day for days1 through 6 per admissionYou pay nothing for day 7 andbeyond per admission 225 copayment per day for days1 through 7 per admissionYou pay nothing for day 8 andbeyond per admission 225 copayment per day for days1 through 7 per admissionYou pay nothing for day 8 andbeyond per admission 200 copayment per day for days1 through 7 per admissionYou pay nothing for day 8 andbeyond per admission 200 copayment per day for days1 through 7 per admissionYou pay nothing for day 8 andbeyond per admission 1,020 maximum per admission190-day lifetime maximum in amental health facility 1,575 maximum per admission190-day lifetime maximum in amental health facility 1,575 maximum per admission190-day lifetime maximum in amental health facility 1,400 maximum per admission190-day lifetime maximum in amental health facility 1,400 maximum per admission190-day lifetime maximum in amental health facility Outpatient IndividualTherapy 40 copayment 40 copayment 40 copayment 40 copayment 40 copayment Outpatient GroupTherapy Visits 40 copayment 40 copayment 40 copayment 40 copayment 40 copaymentServices with a (1) may require prior authorization.89
Keystone 65Focus Rx HMOKeystone 65 SelectMedical-only HMOKeystone 65Select Rx HMOKeystone 65 PreferredMedical-only HMOKeystone 65Preferred Rx HMOYou pay nothing per day for days1 through 20You pay nothing per day for days1 through 20You pay nothing per day for days1 through 20You pay nothing per day for days1 through 20You pay nothing per day for days1 through 20 164 copayment per day for days21 through 100 164 copayment per day for days21 through 100 164 copayment per day for days21 through 100 140 copayment per day for days21 through 100 140 copayment per day for days21 through 100100 days per benefit period100 days per benefit period100 days per benefit period100 days per benefit period100 days per benefit period Occupational Therapy 40 copayment 40 copayment 40 copayment 40 copayment 40 copayment Physical and SpeechTherapy 40 copayment 40 copayment 40 copayment 40 copayment 40 copayment Cardiac RehabilitationTherapy 5 copayment 5 copayment 5 copayment 5 copayment 5 copayment 200 copayment for aone-way trip 200 copayment for aone-way trip 200 copayment for aone-way trip 100 copayment for aone-way trip 100 copayment for aone-way tripNon-emergency ambulanceservices require priorauthorizationNon-emergency ambulanceservices require priorauthorizationNon-emergency ambulanceservices require priorauthorizationNon-emergency ambulanceservices require priorauthorizationNon-emergency ambulanceservices require priorauthorizationTransportationNot coveredNot coveredNot coveredNot coveredNot coveredPodiatry Services (2) 40 copayment per visit forMedicare-covered routinefoot care 45 copayment per visit forMedicare-covered routinefoot care 45 copayment per visit forMedicare-covered routinefoot care 40 copayment per visit forMedicare-covered routinefoot care 40 copayment per visit forMedicare-covered routinefoot care 40 copayment per visit fornon-Medicare-covered routinefoot care (up to 6 visitseach year) 45 copayment per visit fornon-Medicare-covered routinefoot care (up to 6 visitseach year) 45 copayment per visit fornon-Medicare-covered routinefoot care (up to 6 visitseach year) 40 copayment per visit fornon-Medicare-covered routinefoot care (up to 6 visitseach year) 40 copayment per visit fornon-Medicare-covered routinefoot care (up to 6 visitseach year)20% coinsurance20% coinsurance20% coinsurance0-20% coinsurance20% coinsuranceFor a description of the types ofdrugs available under Part B, seeyour Evidence of CoverageFor a description of the types ofdrugs available under Part B, seeyour Evidence of CoverageFor a description of the types ofdrugs available under Part B, seeyour Evidence of CoverageFor a description of the types ofdrugs available under Part B, seeyour Evidence of CoverageFor a description of the types ofdrugs available under Part B, seeyour Evidence of CoverageSkilled Nursing Facility (1)Rehabilitation Services (2)Ambulance (1)Durable Medical Equipmentand Prosthetic Devices andRelated Supplies (1)Services with a (1) may require prior authorization.Services with a (2) may require a referral from your doctor.1011
Keystone 65Focus Rx HMOWellness ProgramsPart B Drugs12Keystone 65 SelectMedical-only HMOKeystone 65Select Rx HMOKeystone 65 PreferredMedical-only HMOKeystone 65Preferred Rx HMOSilverSneakers included at noadditional costSilverSneakers included at noadditional costSilverSneakers included at noadditional costSilverSneakers included at noadditional costSilverSneakers included at noadditional cost24/7 Toll-free nurse hotlineincluded at no additional cost24/7 Toll-free nurse hotlineincluded at no additional cost24/7 Toll-free nurse hotlineincluded at no additional cost24/7 Toll-free nurse hotlineincluded at no additional cost24/7 Toll-free nurse hotlineincluded at no additional costDisease Management included atno additional costDisease Management included atno additional costDisease Management included atno additional costDisease Management included atno additional costDisease Management included atno additional costAccess to a health coach includedat no additional costAccess to a health coach includedat no additional costAccess to a health coach includedat no additional costAccess to a health coach includedat no additional costAccess to a health coach includedat no additional cost20% coinsurance for Part Bdrugs such as chemotherapydrugs20% coinsurance for Part Bdrugs such as chemotherapydrugs20% coinsurance for Part Bdrugs such as chemotherapydrugs20% coinsurance for Part Bdrugs such as chemotherapydrugs20% coinsurance for Part Bdrugs such as chemotherapydrugs20% coinsurance for otherPart B drugs20% coinsurance for otherPart B drugs20% coinsurance for otherPart B drugs20% coinsurance for otherPart B drugs20% coinsurance for otherPart B drugs13
Prescription Drug Benefits (Part D)Available for members of Keystone 65 Focus Rx HMO, Keystone 65 Select Rx HMO, andKeystone 65 Preferred Rx HMO. Not available for members of Keystone 65 Select Medical-onlyHMO and Keystone 65 Preferred Medical-only HMOKeystone 65Focus Rx HMOInitial CoverageCost-sharing may change as youmove into another phase ofPart D benefits. For information,please review the Keystone 65Focus Rx HMO Evidence ofCoverage.Keystone 65Select Rx HMOKeystone 65 PreferredMedical-only HMOAfter you pay your yearlydeductible, you pay the followinguntil your total yearly drug costsreach 3,700. “Total yearly drugcosts” are the total drug costs paidby both you and our Part D plan.You pay the following until yourtotal yearly drug costs reach 3,700. “Total yearly drug costs”are the total drug costs paid byboth you and our Part D plan.You may get your drugs atnetwork retail pharmacies andmail order pharmacies.14Keystone 65 SelectMedical-only HMOPrescription Drug Benefits (Part D)Available for members of Keystone 65 Focus Rx HMO, Keystone 65 Select Rx HMO, andKeystone 65 Preferred Rx HMO. Not available for members of Keystone 65 Select Medical-onlyHMO and Keystone 65 Preferred Medical-only HMOPart D prescription drugs arenot available with this planYou may get your drugs at networkretail pharmacies and mail orderpharmacies.Cost-sharing may change as youmove into another phase ofPart D benefits. For information,please review the Keystone 65Select Rx HMO Evidence ofCoverage.Keystone 65Preferred Rx HMOYou pay the following until yourtotal yearly drug costs reach 3,700. “Total yearly drug costs”are the total drug costs paid byboth you and our Part D plan.Part D prescription drugs arenot available with this planYou may get your drugs at network retail pharmacies and mailorder pharmacies.Cost-sharing may change as youmove into another phase ofPart D benefits. For information,please review the Keystone 65Preferred Rx HMO Evidence ofCoverage.15
Keystone 65 Focus Rx(HMO)Retail Cost-sharing(what you pay at apharmacy location)TierKeystone 65 SelectMedical-only (HMO)Keystone 65 Select Rx (HMO)Retail Cost-sharing(what you pay at apharmacy location)Keystone 65 PreferredMedical-only (HMO)Keystone 65 Preferred Rx(HMO)Retail Cost-sharing(what you pay at apharmacy MonthSupplyTwoMonthSupplyThreeMonthSupplyPreferred Pharmacy 2copayment 4copayment 6copayment 3copayment 6copayment 9copayment 2copayment 4copayment 6copaymentStandard Pharmacy 7copayment 14copayment 21copayment 9copayment 18copayment 27copayment 7copayment 14copayment 21copaymentPreferred Pharmacy 15copayment 30copayment 45copayment 12copayment 24copayment 36copayment 10copayment 20copayment 30copaymentStandard Pharmacy 20copayment 40copayment 60copayment 18copayment 36copayment 54copayment 16copayment 32copayment 48copaymentPreferred Pharmacy 47copayment 94copayment 141copayment 47copayment 94copayment 141copayment 47copayment 94copayment 141copaymentStandard Pharmacy 47copayment 94copayment 141copayment 47copayment 94copayment 141copayment 47copayment 94copayment 141copaymentPreferred Pharmacy 100copayment 200copayment 300copayment 100copayment 200copayment 300copayment 100copayment 200copayment 300copaymentStandard Pharmacy 100copayment 200copayment 300copayment 100copayment 200copayment 300copayment 100copayment 200copayment 300copaymentPreferred Pharmacy33% ofthe cost33% ofthe cost33% ofthe cost25% ofthe cost25% ofthe cost25% ofthe cost33% ofthe cost33% ofthe cost33% ofthe costStandard Pharmacy33% ofthe cost33% ofthe cost33% ofthe cost25% ofthe cost25% ofthe cost25% ofthe cost33% ofthe cost33% ofthe cost33% ofthe costTier 1 (Preferred Generic Drugs)Tier 2 (Generic Drugs)Tier 3 (Preferred Brand-Name Drugs)Tier 4 (Non-Preferred Generic andBrand-Name Drugs)Tier 5 (Specialty Drugs)1617
Keystone 65 Focus Rx(HMO)Mail Order Cost-sharing(what you pay when you order aprescription by mail)18Keystone 65 SelectMedical-only (HMO)Keystone 65 Select Rx (HMO)Mail Order Cost-sharing(what you pay when you ordera prescription by mail)Keystone 65 PreferredMedical-0nly (HMO)Keystone 65 Preferred Rx(HMO)Mail Order Cost-sharing(what you pay when you ordera prescription by MonthSupplyTwoMonthSupplyThreeMonthSupplyTier 1 2copayment 4copayment 4copayment 3copayment 6copayment 6copayment 2copayment 4copayment 4copaymentTier 2 (Generic Drugs) 15copayment 30copayment 30copayment 12copayment 24copayment 24copayment 10copayment 20copayment 20copaymentTier 3 (Preferred Brand-Name Drugs) 47copayment 94copayment 94copayment 47copayment 94copayment 94copayment 47copayment 94copayment 94copaymentTier 4 (Non-Preferred Generic andBrand-Name Drugs) 100copayment 200copayment 200copayment 100copayment 200copayment 200copayment 100copayment 200copayment 200copaymentTier 5 (Specialty Drugs)33% of thecost33% ofthe cost33% ofthe cost25% ofthe cost25% ofthe cost25% ofthe cost33% ofthe cost33% ofthe cost33% ofthe cost19
Keystone 65 Focus Rx(HMO)Coverage GapCatastrophic CoverageKeystone 65 Select Rx (HMO)Keystone 65 PreferredMedical-only (HMO)Keystone 65 Preferred Rx(HMO)If you reside in a long-term carefacility, you pay the same as at aretail pharmacy. This plan has apreferred pharmacy network;cost-sharing for drugs may varydepending on the pharmacy used.If you reside in a long-term carefacility, you pay the same as at aretail pharmacy. This plan has apreferred pharmacy network;cost-sharing for drugs may varydepending on the pharmacy used.If you reside in a long-term carefacility, you pay the same as at aretail pharmacy. This plan has apreferred pharmacy network;cost-sharing for drugs may varydepending on the pharmacy used.You may get drugs from anout-of-network pharmacy at thesame cost as an in-networkpharmacy.You may get drugs from anout-of-network pharmacy at thesame cost as an in-networkpharmacy.You may get drugs from anout-of-network pharmacy at thesame cost as an in-networkpharmacy.Most Medicare drug plans havea coverage gap (also called the“donut hole”). This means thatthere’s a temporary change in whatyou will pay for your drugs. Thecoverage gap begins after the totalyearly drug cost (including what ourplan has paid and what you havepaid) reaches 3,700.Most Medicare drug plans havea coverage gap (also called the“donut hole”). This means thatthere’s a temporary change in whatyou will pay for your drugs. Thecoverage gap begins after the totalyearly drug cost (including what ourplan has paid and what you havepaid) reaches 3,700.Most Medicare drug plans havea coverage gap (also called the“donut hole”). This means thatthere’s a temporary change in whatyou will pay for your drugs. Thecoverage gap begins after the totalyearly drug cost (including what ourplan has paid and what you havepaid) reaches 3,700.Part D prescription drugs arenot available with this planPart D prescription drugs arenot available with this planAfter you enter the coverage gap,you pay 40% of the plan’s cost forcovered brand-name drugs and 51%of the plan’s cost for covered genericdrugs until your costs total 4,950,which is the end of the coverage gap.Not everyone will enter the coveragegap.After you enter the coverage gap,you pay 40% of the plan’s costfor covered brand-name drugs and51% of the plan’s cost for coveredgeneric drugs until your costs total 4,950, which is the end of thecoverage gap. Not everyone willenter the coverage gap.After you enter the coverage gap,you pay 40% of the plan’s cost forcovered brand-name drugs and 51%of the plan’s cost for covered genericdrugs until your costs total 4,950,which is the end of the coverage gap.Not everyone will enter the coveragegap.After your yearly out-of-pocketdrug costs (including drugspurchased through your retailpharmacy and through mailorder) reach 4,950, you paythe greater of:After your yearly out-of-pocketdrug costs (including drugspurchased through your retailpharmacy and through mailorder) reach 4,950, you paythe greater of:After your yearly out-of-pocketdrug costs (including drugspurchased through your retailpharmacy and through mailorder) reach 4,950, you paythe greater of: 5% of the costs, or; 3.30 copayment forgeneric (including brand drugstested as generic) and an 8.25copayment for all other drugs20Keystone 65 SelectMedical-only (HMO)Part D prescription drugs arenot available with this plan 5% of the costs, or; 3.30 copayment forgeneric (including brand drugstested as generic) and an 8.25copayment for all other drugsPart D prescription drugs arenot available with this plan 5% of the costs, or; 3.30 copayment forgeneric (including brand drugstested as generic) and an 8.25copayment for all other drugs21
Other Medical BenefitsKeystone 65 Focus Rx(HMO)Keystone 65 SelectMedical-only (HMO)Keystone 65 Select Rx(HMO)Other Medical BenefitsKeystone 65 PreferredMedical-0nly (HMO)Keystone 65 Preferred Rx(HMO)Chiropractic Services 20 copayment per visit fornon-Medicare-covered routinechiropractic care (up to6 visits each year) 20 copayment per visit fornon-Medicare-covered routinechiropractic care (up to6 visits each year) 20 copayment per visit fornon-Medicare-covered routinechiropractic care (up to6 visits each year) 20 copayment per visit fornon-Medicare-covered routinechiropractic care (up to6 visits each year) 20 copayment per visit fornon-Medicare-covered routinechiropractic care (up to6 visits each year)Ambulatory SurgicalCenter(1) 175 copayment 200 copayment 200 copayment 125 copayment 125 copaymentOutpatient HospitalFacility(1) 250 copayment 400 copayment 400 copayment 400 copayment 400 copaymentServices with a (1) may require prior authorization.2223
Optional Benefits(you must pay an extra premium each month for these benefits)24Optional Benefits(you must pay an extra premium each month for these benefits)Keystone 65 Focus Rx(HMO)Keystone 65 SelectMedical-0nly (HMO)Keystone 65 Select Rx(HMO)Keystone 65 PreferredMedical-only (HMO)Keystone 65 Preferred Rx(HMO)Choice ProgramBenefits include: Routine Dental
Keystone 65 Focus 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.
