2015 Summary of Benefits

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1 2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014

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3 Section I: Introduction to 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 Basic Rx (HMO), Keystone 65 Select, Keystone 65 Select Rx (HMO), Keystone 65 Preferred, 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 Basic Rx (HMO), Keystone 65 Select, Keystone 65 Select Rx (HMO), Keystone 65 Preferred, 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 Basic Rx (HMO), Keystone 65 Select, Keystone 65 Select Rx (HMO), Keystone 65 Preferred, and Keystone 65 Preferred Rx (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits for Keystone 65 Basic Rx (HMO), Keystone 65 Select Rx (HMO), and Keystone 65 Preferred Rx (HMO). Optional Benefits (you must pay an extra premium for these benefits) for Keystone 65 Basic Rx (HMO), Keystone 65 Select, 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 Basic Rx (HMO), Keystone 65 Select Medical Only (HMO), Keystone 65 Select Rx (HMO), Keystone 65 Preferred, 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 Section I: Introduction to Summary of Benefits Keystone 65 Basic Rx (HMO), Keystone 65 Select, Keystone 65 Select Rx (HMO), Keystone 65 Preferred, 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. Our website: Who can join? To join Keystone 65 Basic Rx (HMO), Keystone 65 Select, Keystone 65 Select Rx (HMO), Keystone 65 Preferred, 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, Keystone 65 Select Rx (HMO), Keystone 65 Preferred, and Keystone 65 Preferred Rx (HMO): Our service area includes the following counties in Pennsylvania: Bucks, Chester, Delaware, Montgomery, and Philadelphia. Keystone 65 Basic Rx (HMO): Our service area includes the following counties in Pennsylvania: Bucks and Philadelphia. Which doctors, hospitals, and pharmacies can I use? Keystone 65 Basic Rx (HMO), Keystone 65 Select, Keystone 65 Select Rx (HMO), Keystone 65 Preferred, 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 Basic 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. You can see our plans provider/pharmacy directories at our website (http://www.ibxmedicare.com). Or, call us and we will send you a copy of the provider/pharmacy directories. 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. Some of the extra benefits are outlined in this booklet. Keystone 65 Basic 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. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. Keystone 65 Select and Keystone 65 Preferred 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 Basic Rx (HMO), Keystone 65 Select Rx (HMO) and Keystone 65 Preferred 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. If you have any questions about these plans benefits or s, please contact Keystone 65 HMO for details. 2

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6 Keystone 65 Basic Rx (HMO) Keystone 65 Select 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 has deductibles for some hospital and medical services, and Part D prescription drugs. $450 per year for in-network services. $320 per year for Part D prescription drugs. 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: $6,700 for services you receive 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: $6,700 for services you receive 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 Keystone 65 Select Rx (HMO) Keystone 65 Preferred Keystone 65 Preferred Rx (HMO) 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. $320 per year for Part D prescription drugs. 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: $6,700 for services you receive 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: $5,000 for services you receive 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 out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $5,000 for services you receive 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? Keystone 65 Basic Rx (HMO) Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Keystone 65 Select Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Keystone 65 HMO is an HMO plan with a Medicare contract. Enrollment in Keystone 65 HMO depends on contract renewal. 6

9 Keystone 65 Select Rx (HMO) Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Keystone 65 Preferred Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Keystone 65 Preferred Rx (HMO) Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Keystone 65 HMO is an HMO plan with a Medicare contract. Enrollment in Keystone 65 HMO depends on contract renewal. 7

10 Keystone 65 Basic Rx (HMO) Keystone 65 Select Covered Medical and Hospital Benefits NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. Outpatient Care and Services Acupuncture and Other Alternative Therapies Not covered Not covered Ambulance 1 $225 Copayment not waived if admitted. $150 Copayment not waived if admitted. Chiropractic Care 2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 8

11 Keystone 65 Select Rx (HMO) Keystone 65 Preferred Keystone 65 Preferred Rx (HMO) Covered Medical and Hospital Benefits NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. Outpatient Care and Services NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. Not covered Not covered Not covered $150 Copayment not waived if admitted. $100 Copayment not waived if admitted. $100 Copayment not waived if admitted. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 9

12 Dental Services 2 Keystone 65 Basic Rx (HMO) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-50, depending on the service This plan covers some preventive dental benefits for an extra (see Optional Benefits. ) Keystone 65 Select 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 This plan covers some preventive dental benefits for an extra (see Optional Benefits. ) 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 Keystone 65 Select Rx (HMO) 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 This plan covers some preventive dental benefits for an extra (see Optional Benefits. ) Keystone 65 Preferred 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: Cleaning (for up to 1 every six months) Oral exam (for up to 1 every six months) Keystone 65 Preferred Rx (HMO) 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: Cleaning (for up to 1 every six months) Oral exam (for up to 1 every six 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 Keystone 65 Basic Rx (HMO) Diagnostic radiology services (such as MRIs, CT scans): $60-200, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $60 Therapeutic radiology services (such as radiation treatment for cancer): 20% of the For diagnostic tests, procedures and lab services, a separate office ment may apply. Keystone 65 Select Diagnostic radiology services (such as MRIs, CT scans): $50-150, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $50 Therapeutic radiology services (such as radiation treatment for cancer): $60 For diagnostic tests, procedures and lab services, a separate office ment may apply. Doctor s Office Visits 2 Primary care physician visit: $20 Specialist visit: $50 Primary care physician visit: $20 Specialist visit: $45 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 10% of the After the in-network deductible is met 20% of the Emergency Care $65 Worldwide coverage, ment not waived if admitted. $65 Worldwide coverage, ment not waived if admitted. Foot Care (podiatry services) 2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $45 12

15 Keystone 65 Select Rx (HMO) Diagnostic radiology services (such as MRIs, CT scans): $50-150, depending on the service Diagnostic tests and procedures: Lab services: Outpatient X-rays: $50 Therapeutic radiology services (such as radiation treatment for cancer): $60 For diagnostic tests, procedures and lab services, a separate office ment may apply. Keystone 65 Preferred 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 For diagnostic tests, procedures and lab services, a separate office ment may apply. Keystone 65 Preferred Rx (HMO) 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 For diagnostic tests, procedures and lab services, a separate office ment may apply. Primary care physician visit: $20 Specialist visit: $45 Primary care physician visit: $10 Specialist visit: $40 Primary care physician visit: $10 Specialist visit: $40 20% of the 20% of the 20% of the $65 Worldwide coverage, ment not waived if admitted. $65 Worldwide coverage, ment not waived if admitted. $65 Worldwide coverage, ment not waived if admitted. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $45 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 13

16 Hearing Services 2 Keystone 65 Basic Rx (HMO) Exam to diagnose and treat hearing and balance issues: $50 This plan covers some hearing benefits for an extra (see Optional Benefits. ) Keystone 65 Select Exam to diagnose and treat hearing and balance issues: $45 This plan covers some hearing benefits for an extra (see Optional Benefits. ) Home Health Care 1 14

17 Keystone 65 Select Rx (HMO) Exam to diagnose and treat hearing and balance issues: $45 This plan covers some hearing benefits for an extra (see Optional Benefits. ) Keystone 65 Preferred Exam to diagnose and treat hearing and balance issues: $40 Routine hearing exam (for up to 1 every three years): $40 Hearing aid fitting/evaluation (for up to 2 every three years): $40 Hearing aid: Our plan pays up to $500 every three years for hearing aids. Amounts above $500 are the member s responsibility. Keystone 65 Preferred Rx (HMO) Exam to diagnose and treat hearing and balance issues: $40 Routine hearing exam (for up to 1 every three years): $40 Hearing aid fitting/evaluation (for up to 2 every three years): $40 Hearing aid: Our plan pays up to $500 every three years for hearing aids. Amounts above $500 are the member s responsibility. 15

18 Mental Health Care 1 Keystone 65 Basic Rx (HMO) 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 reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $450 deductible $215 per day for days 1 through 7 per day for days 8 through 90 Inpatient Mental Health visit only: After the in-network deductible is met Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 Keystone 65 Select 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 reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $215 per day for days 1 through 7 per day for days 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 16

19 Keystone 65 Select Rx (HMO) 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 reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Keystone 65 Preferred 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 reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Keystone 65 Preferred Rx (HMO) 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 reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $215 per day for days 1 through 7 per day for days 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 $200 per day for days 1 through 7 per day for days 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 $200 per day for days 1 through 7 per day for days 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 17

20 Outpatient Rehabilitation 2 Keystone 65 Basic Rx (HMO) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $40 Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Keystone 65 Select Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $45 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: $0-300, depending on the service Ambulatory surgical center: $150 Outpatient hospital: $0-400, depending on the service After the in-network deductible is met Over-the-Counter Items Not Covered Not Covered 18

21 Keystone 65 Select Rx (HMO) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $45 Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Keystone 65 Preferred Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $40 Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 Keystone 65 Preferred Rx (HMO) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $40 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: $0-400, depending on the service Ambulatory surgical center: $125 Outpatient hospital: $0-400, depending on the service Ambulatory surgical center: $125 Outpatient hospital: $0-400, depending on the service Not Covered Not Covered Not Covered 19

22 Prosthetic Devices (braces, artificial limbs, etc.) 1 Keystone 65 Basic Rx (HMO) Prosthetic devices: 10% of the Related medical supplies: 10% of the Keystone 65 Select Prosthetic devices: 20% of the Related medical supplies: 20% of the After the in-network deductible is met Renal Dialysis 20% of the 20% of the Transportation Not covered Not covered Urgent Care $20-50, depending on the service $20-45, depending on the service Vision Services 2 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-50, depending on the service Eyeglasses or contact lenses after cataract surgery: You pay nothing This plan covers some vision benefits for an extra (see Optional Benefits. ) Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-45, depending on the service Eyeglasses or contact lenses after cataract surgery: This plan covers some vision benefits for an extra (see Optional Benefits. ) 20

23 Keystone 65 Select Rx (HMO) Prosthetic devices: 20% of the Related medical supplies: 20% of the Keystone 65 Preferred Prosthetic devices: 20% of the Related medical supplies: 20% of the Keystone 65 Preferred Rx (HMO) 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 $10-40, depending on the service $10-40, depending on the service Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-45, depending on the service Eyeglasses or contact lenses after cataract surgery: This plan covers some vision benefits for an extra (see Optional Benefits. ) Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-40, depending on the service Routine eye exam (for up to 1 every two years): $40 Contact lenses (for up to 1 every two years): Eyeglass frames (for up to 1 every two years): Eyeglass lenses (for up to 1 every two years): Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $100 every two years for contact lenses, eyeglass lenses, and eyeglass frames. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-40, depending on the service Routine eye exam (for up to 1 every two years): $40 Contact lenses (for up to 1 every two years): Eyeglass frames (for up to 1 every two years): Eyeglass lenses (for up to 1 every two years): Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $100 every two years for contact lenses, eyeglass lenses, and eyeglass frames. 21

24 Preventive Care Keystone 65 Basic Rx (HMO) Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobaccorelated disease) Keystone 65 Select Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 22

25 Keystone 65 Select Rx (HMO) Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Keystone 65 Preferred Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counselling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Keystone 65 Preferred Rx (HMO) Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 23

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