201 Summary of Benefits

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1 201 Summary of Benefits Effective January 1, 201 through December 31, 201 H3952

2

3 Summary of Benefits You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare 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 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 choices This Summary of Benefits booklet gives you a summary of what Keystone 65 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) cover and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and s of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Keystone 65 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 Services Covered Medical and Hospital Benefits Keystone 65 Rx (HMO), Keystone 65 Select Rx (HMO), and Keystone 65 Preferred Rx (HMO). Keystone 65 x (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) TTY/TDD 711. Things to Know About Keystone 65 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) Hours of Operation From 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

4 ummary of Benefits Keystone 65 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) Phone Numbers and Website If you are a member of these plans, call toll-free (800) TTY/TDD 711. If you are not a member of these plans, call toll-free (877) TTY/TDD 711. Who can join? To join Keystone 65 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 be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. 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 area includes the following counties in Pennsylvania: Bucks, Chester, Delaware, Montgomery, and Philadelphia. Which doctors, hospitals, and pharmacies can I use? Keystone 65 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. For Keystone 65 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. Or, call us and we will send you a copy of the provider/pharmacy 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, you may 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. are outlined in this booklet. Keystone 65 Rx (HMO), Keystone 65 Select Rx (HMO) and Keystone 65 Preferred Rx (HMO): We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. Keystone 65 Select Medical Only (HMO) and Keystone 65 Preferred Medical Only (HMO) cover Part B drugs including chemotherapy and some drugs administered by your provider. However, these plans do not cover Part D prescription drugs. How will I determine my drug s? Our Keystone 65 Select Rx (HMO) plans group each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 2

5 ummary of Benefits Our 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 you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 3

6 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? Please refer to the Premium / Cost-Sharing Table to find out the premium/-sharing in your area. In addition, you must keep paying your Medicare Part B premium. Please refer to the Premium / Cost-Sharing Table to find out the premium/-sharing in your area. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan does not have a deductible. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums. 4

7 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Please refer to the Premium / Cost-Sharing Table to find out the premium/-sharing in your area. In addition, you must keep paying your Medicare Part B premium. Please refer to the Premium / Cost-Sharing Table to find out the premium/-sharing in your area. In addition, you must keep paying your Medicare Part B premium. Please refer to the Premium / Cost-Sharing Table to find out the premium/-sharing in your area. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. 5

8 Is there a limit on how much the plan will pay? 6

9 Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 7

10 Covered Medical and Hospital Benefits NOTE: SERVICES WITH 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH 2 MA REQUIRE A REFERRAL FROM YOUR DOCTOR. NOTE: SERVICES WITH 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH 2 MA Y REQUIRE A REFERRAL FROM YOUR DOCTOR. Outpatient Care and Services Acupuncture Not covered Not covered Ambulance 1 $ 5 $ Chiropractic Care 2 Manipulation of the spine to more of the bones of your spine move out of position): $20 Manipulation of the spine to more of the bones of your spine move out of position): $20 8

11 Covered Medical and Hospital Benefits NOTE: SERVICES WITH 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH 2 MA Y REQUIRE A REFERRAL FROM YOUR DOCTOR. Outpatient Care and Services NOTE: SERVICES WITH 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. NOTE: SERVICES WITH 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH 2 MA Y REQUIRE A REFERRAL FROM YOUR DOCTOR. Not covered Not covered Not covered $ 0 $100 $100 Manipulation of the spine to more of the bones of your spine move out of position): $20 Manipulation of the spine to more of the bones of your spine move out of position): $20 Manipulation of the spine to correct the bones of your spine move out of position): $20 9

12 Dental Services 2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-, depending on the service Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-45, depending on the service Diabetes Supplies and Services 1 Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: 10

13 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-45, depending on the service Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-40, depending on the service Dental services: $20 for a single office visit that includes: months) months) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-40, depending on the service Dental services: $20 for a single office visit that includes: months) months) Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: 11

14 Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 Diagnostic radiology services (such as MRIs, CT scans): $ -, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $ 0 Therapeutic radiology services (such as radiation treatment for cancer): Diagnostic radiology services (such as MRIs, CT scans): $50-1, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $50 Therapeutic radiology services (such as radiation treatment for cancer): $60 Doctor s Office Visits 2 Primary care physician visit: $ 0 Specialist visit: $ Primary care physician visit: $20 Specialist visit: $45 Durable Medical Equipment (wheelchairs, oxygen, etc.) 0% of the 20% of the Emergency Care $ 5 $ 5 Foot Care (podiatry services) you have diabetes-related nerve damage and/or meet certain conditions: $ 0 12 you have diabetes-related nerve damage and/or meet certain conditions: $45

15 Diagnostic radiology services (such as MRIs, CT scans): $50-, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $ Therapeutic radiology services (such as radiation treatment for cancer): $60 Diagnostic radiology services (such as MRIs, CT scans): $40-125, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $40 Therapeutic radiology services (such as radiation treatment for cancer): $60 Diagnostic radiology services (such as MRIs, CT scans): $40-125, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $40 Therapeutic radiology services (such as radiation treatment for cancer): $60 Primary care physician visit: $20 Specialist visit: $45 Primary care physician visit: $ Specialist visit: $40 Primary care physician visit: $ Specialist visit: $40 20% of the 20% of the 20% of the $ 5 $ 5 $ 5 you have diabetes-related nerve damage and/or meet certain conditions: $45 you have diabetes-related nerve damage and/or meet certain conditions: $40 13 have diabetes-related nerve damage and/or meet certain conditions: $40

16 Hearing Services 2 hearing and balance issues: $ 0 hearing and balance issues: $45 Home Health Care 1 14

17 hearing and balance issues: $45 hearing and balance issues: $40 every three years): $40 Hearing aid fitting/evaluation (for up to 2 every year): Hearing aid and balance issues: $40 every three years): $40 Hearing aid fitting/evaluation (for up to 2 every years): 15

18 Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime days that we cover. If your hospital stay is longer than 90 days, you 60 days, your inpatient hospital coverage will be limited to 90 days. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime days that we cover. If your hospital stay is longer than 90 days, you 60 days, your inpatient hospital coverage will be limited to 90 days. through through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 through 7 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 16

19 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime days that we cover. If your hospital stay is longer than 90 days, you 60 days, your inpatient hospital coverage will be limited to 90 days. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime days that we cover. If your hospital stay is longer than 90 days, you 60 days, your inpatient hospital coverage will be limited to 90 days. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime days that we cover. If your hospital stay is longer than 90 days, you can your inpatient hospital coverage will be limited to 90 days. through 7 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 through 7 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 through 7 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 17

20 Outpatient Rehabilitation 2 Cardiac (heart) rehab services (for per day for up to 36 sessions up to 36 weeks): $ Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Cardiac (heart) rehab services (for per day for up to 36 sessions up to 36 weeks): $ Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Outpatient Substance Abuse Group therapy visit: $40 Individual therapy visit: $40 Group therapy visit: $40 Individual therapy visit: $40 Outpatient Surgery 1 Ambulatory surgical center: $150 Outpatient hospital: $ Ambulatory surgical center: $150 Outpatient hospital: $400 Over-the-Counter Items Not Covered Not Covered 18

21 Cardiac (heart) rehab services (for per day for up to 36 sessions up to 36 weeks): $5 Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Cardiac (heart) rehab services (for per day for up to 36 sessions up to 36 weeks): $ Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Cardiac (heart) rehab services (for per day for up to 36 sessions up to 36 weeks): $ Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Group therapy visit: $40 Individual therapy visit: $40 Group therapy visit: $40 Individual therapy visit: $40 Group therapy visit: $40 Individual therapy visit: $40 Ambulatory surgical center: $150 Outpatient hospital: $400 Ambulatory surgical center: $125 Outpatient hospital: $400 Ambulatory surgical center: $125 Outpatient hospital: $400 Not Covered Not Covered Not Covered 19

22 Prosthetic Devices (braces, artificial limbs, etc.) Prosthetic devices: 0% of the Related medical supplies: 0% of the Prosthetic devices: 20% of the Related medical supplies: 20% of the Renal Dialysis 20% of the 20% of the Transportation Not covered Not covered Urgent $ 0-0, depending on the service $20-45, depending on the service Vision Services 2 diseases and conditions of the eye (including yearly glaucoma screening): $0-0, depending on the service Eyeglasses or contact lenses after cataract surgery: diseases and conditions of the eye (including yearly glaucoma screening): $0-45, depending on the service Eyeglasses or contact lenses after cataract surgery: 20

23 Prosthetic devices: 20% of the Related medical supplies: 20% of the Prosthetic devices: 20% of the Related medical supplies: 20% of the 20% of the 20% of the 20% of the Not covered Not covered Not covered $20-45, depending on the service $ -40, depending on the service $ -40, depending on the service diseases and conditions of the eye (including yearly glaucoma screening): $0-45, depending on the service Eyeglasses or contact lenses after cataract surgery: diseases and conditions of the eye (including yearly glaucoma screening): $0-40, depending on the service every two years): $40 Contact lenses (for up to 1 every two years): Eyeglasses or contact lenses after cataract surgery: and conditions of the eye (including yearly glaucoma screening): $0-40, depending on the service two years): $40 Contact lenses (for up to 1 every two years): Eyeglasses or contact lenses after cataract surgery: 21

24 Preventive Care Our plan covers many preventive services, including: screening (mammogram) (behavioral therapy) screening services counseling (PSA) screening and counseling counseling (counseling for people with no sign of tobaccorelated disease) Our plan covers many preventive services, including: screening (mammogram) (behavioral therapy) screening services (PSA) screening and counseling (counseling for people with no sign of tobaccorelated disease) 22

25 Our plan covers many preventive services, including: screening (mammogram) (behavioral therapy) screening services (PSA) screening and counseling (counseling for people with no sign of tobaccorelated disease) Our plan covers many preventive services, including: screening (mammogram) (behavioral therapy) screening services (PSA) screening and counseling (counseling for people with no sign of tobacco-related disease) Our plan covers many preventive services, including: screening (mammogram) therapy) screening screening and counseling (counseling for people with no sign of tobacco-related disease) 23

26 Preventive Care shots, Hepatitis B shots, Pneumococcal shots preventive visit (one-time) Any additional preventive services approved by Medicare during the contract year will be covered. Hepatitis B shots, Pneumococcal shots preventive visit (one-time) Any additional preventive services approved by Medicare during the contract year will be covered. Hospice Inpatient Care rom certified ro certified Inpatient Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. through days through 90 days 91 and beyond $2 0 per day for days 1 through through and beyond 24

27 Hepatitis B shots, Pneumococcal shots preventive visit (one-time) Any additional preventive services approved by Medicare during the contract year will be covered. Hepatitis B shots, Pneumococcal shots preventive visit (one-time) Any additional preventive services approved by Medicare during the contract year will be covered. Hepatitis B shots, Pneumococcal shots preventive visit (one-time) Any additional preventive services approved by Medicare during the contract year will be covered. ro certified Inpatient Care ro certified certified Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. through through and beyond 0 per day for days 1 through through and beyond 40 per day for days 1 through through and beyond 25

28 Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. days 1 through 20 $1 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. $1 0 per day for days 21 through 100 Prescription Drug Benefits How much do I pay? Initial Coverage For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the You may get your drugs at network retail pharmacies and mail order pharmacies. For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the Our plan does not cover Part D prescription drugs. 26

29 For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. $1 0 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. $140 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. $140 per day for days 21 through 100 Prescription Drug Benefits For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the After you pay your yearly deductible, you pay the following until your total yearly drug s reach $,. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the Our plan does not cover Part D prescription drugs For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the You pay the following until your total yearly drug s reach $. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. 27

30 Tier Standard Retail Cost-Sharing One- Month Supply Two- Month Supply Three- Month Supply Tier 1 (Preferred Generic) $ $ $ Tier 2 (Generic) $1 $ $ Tier 3 (Preferred Brand) $4 $9 $1 Tier 4 (Non-Preferred Brand) $ $ $ Tier 5 (Specialty Tier) % of the % of the % of the 28

31 Standard Retail Cost-Sharing Standard Retail Cost-Sharing One- Month Supply Two- Month Supply Three- Month Supply One- Month Supply Two- Month Supply Three- Month Supply $ $ $ $ $ $ $1 $2 $3 $8 $16 $24 $4 $9 $1 $45 $90 $135 $ $ $ $9 $19 $2 25% of the 25% of the 25% of the 33% of the 33% of the 33% of the 29

32 Tier One- Month Supply Two- Month Supply Three- Month Supply Tier 1 (Preferred Generic) $ $ $ Tier 2 (Generic) $1 $ $ Tier 3 (Preferred Brand) $4 $9 $9 Tier 4 (Non-Preferred Brand) $ $ $ Tier 5 (Specialty Tier) % of the % of the of the 30

33 31 One- Month Supply Two- Month Supply Three- Month Supply $ $ $ $1 $2 $2 $4 $9 $9 $ $ $ 25% of the 25% of the 25% of the One- Month Supply Two- Month Supply Three- Month Supply $ $ $ $8 $16 $16 $45 $90 $90 $9 $19 $19 33% of the 33% of the 33% of the

34 If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-ofnetwork pharmacy at the same as an in-network pharmacy. Coverage Gap Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and % of the plan s for covered generic drugs until your s total $, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $, you pay the greater of: brand drugs treated as generic) and a $ ment for all other drugs. 32

35 If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-ofnetwork pharmacy at the same as an in-network pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-ofnetwork pharmacy at the same as an in-network pharmacy. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $ 0. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and % of the plan s for covered generic drugs until your s total $, which is the end of the coverage gap. Not everyone will enter the coverage gap. After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $, you pay the greater of: brand drugs treated as generic) and a $. 0 ment for all other drugs. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $, 0. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and % of the plan s for covered generic drugs until your s total $, which is the end of the coverage gap. Not everyone will enter the coverage gap. After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4, 0, you pay the greater of: brand drugs treated as generic) and a $. 0 ment for all other drugs. 33

36 Optional Benefits (you must pay an extra premium each month for these benefits) Package 1: Choice Program Benefits include: Benefits include: How much is the monthly premium? Additional $.00 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. Additional $.00 per month. You must keep paying your Medicare Part B premium and your $ or $ monthly plan premium. How much is the deductible? This package does not have a deductible. This package does not have a deductible. Is there a limit on how much the plan will pay? 34

37 Optional Benefits (you must pay an extra premium each month for these benefits) Benefits include: Additional $.00 per month. You must keep paying your Medicare Part B premium and your $ or $ monthly plan premium. This package does not have a deductible. 35

38 Premium/Cost-Sharing Table If you have any questions about plan, please call (TTY/TDD 711). Keystone 65 Preferred (HMO): And You Have... If You Live In... Keystone 65 Preferred Medical Only (HMO) Keystone 65 (HMO) Per month. In addition, you must keep paying your Medicare Part B premium. Chester, Delaware, or Montgomery County $ $2 Bucks or Philadelphia County $1 $19 Keystone 65 Select (HMO): And You Have... If You Live In... Chester, Delaware, or Montgomery County Bucks or Philadelphia County Keystone 65 Select Medical Only (HMO) Keystone 65 (HMO) Keystone 65 Select Medical Only (HMO) with Optional Supplemental Benefits Keystone 65 with Optional Supplemental Benefits Per month. In addition, you must keep paying your Medicare Part B premium. $ $ $ $ $ $ $ $ Keystone 65 Rx And You Have... If You Live In... Keystone 65 Keystone 65 with Optional Supplemental Benefits Per month. In addition, you must keep paying your Medicare Part B premium. Chester, Delaware, or Montgomery County $ $ Bucks or Philadelphia County $0 $ 36

39 THIS PAGE INTENTIONALLY LEFT BLANK. 37

40 PO Box 7799 Philadelphia, PA For updated information regarding plan providers, visit our website at or call the Member Help Team at TTY/TDD 711 Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voic . If you are not yet a member and have questions, please call or TTY/TDD 711, seven days a week, 8 a.m. to 8 p.m. H3952 KS6 ( /1 )

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