2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014
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 http://www.medicare.gov. 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 http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this 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) 393-6733 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
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) 645-3965. TTY/TDD 711. If you are not a member of these plans, call toll-free (877) 393-6733. TTY/TDD 711. Our website: http://www.ibxmedicare.com 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, http://www.ibxmedicare.com. 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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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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Preventive Care Keystone 65 Basic Rx (HMO) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. $0 ment for a supplemental annual physical exam Keystone 65 Select Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. $0 ment for a supplemental annual physical exam Hospice Inpatient Care for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Inpatient Hosptial Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. $450 deductible $270 per day for days 1 through 7 per day for days 8 through 90 per day for days 91 and beyond Out-of-pocket ments listed are per stay Our plan covers an unlimited number of days for an inpatient hospital stay. $270 per day for days 1 through 7 per day for days 8 through 90 per day for days 91 and beyond Out-of-pocket ments listed are per stay After the in-network deductible is met 24
Keystone 65 Select Rx (HMO) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. $0 ment for a supplemental annual physical exam Keystone 65 Preferred Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. $0 ment for a supplemental annual physical exam Keystone 65 Preferred Rx (HMO) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. $0 ment for a supplemental annual physical exam for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Inpatient Care 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. $270 per day for days 1 through 7 per day for days 8 through 90 per day for days 91 and beyond Out-of-pocket ments listed are per stay $240 per day for days 1 through 7 per day for days 8 through 90 per day for days 91 and beyond Out-of-pocket ments listed are per stay $240 per day for days 1 through 7 per day for days 8 through 90 per day for days 91 and beyond Out-of-pocket ments listed are per stay 25
Inpatient Mental Health Care Keystone 65 Basic Rx (HMO) For inpatient mental health care, see the Mental Health Care section of this booklet. Keystone 65 Select For inpatient mental health care, see the Mental Health Care section of this booklet. After the in-network deductible is met Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. $0 per day for days 1 through 20 $155 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. $0 per day for days 1 through 20 $150 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 After you pay your yearly deductible, you pay the following until your total yearly drug s reach $2,960. 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. 26
Keystone 65 Select Rx (HMO) For inpatient mental health care, see the Mental Health Care section of this booklet. Keystone 65 Preferred For inpatient mental health care, see the Mental Health Care section of this booklet. Keystone 65 Preferred Rx (HMO) For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. $0 per day for days 1 through 20 $150 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. $0 per day for days 1 through 20 $140 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. $0 per day for days 1 through 20 $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 $2,960. 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 $2,960. 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
Standard Retail Cost-Sharing Keystone 65 Basic Rx (HMO) Keystone 65 Select Tier One- Month Supply Two- Month Supply Three- Month Supply Tier 1 (Preferred Generic) $5 $10 $15 Tier 2 (Non-Preferred Generic) $12 $24 $36 Tier 3 (Preferred Brand) $45 $90 $135 Tier 4 (Non-Preferred Brand) $95 $190 $285 Tier 5 (Specialty Tier) 25% of the 25% of the 25% of the 28
Keystone 65 Select Rx (HMO) Standard Retail Cost-Sharing Keystone 65 Preferred Keystone 65 Preferred Rx (HMO) One- Month Supply Two- Month Supply Three- Month Supply One- Month Supply Two- Month Supply Three- Month Supply $4 $8 $12 $3 $6 $9 $10 $20 $30 $8 $16 $24 $45 $90 $135 $45 $90 $135 $95 $190 $285 $95 $190 $285 25% of the 25% of the 25% of the 33% of the 33% of the 33% of the 29
Standard Mail Order Cost-Sharing Keystone 65 Basic Rx (HMO) Keystone 65 Select Tier One- Month Supply Two- Month Supply Three- Month Supply Tier 1 (Preferred Generic) $5 $10 $10 Tier 2 (Non-Preferred Generic) $12 $24 $24 Tier 3 (Preferred Brand) $45 $90 $90 Tier 4 (Non-Preferred Brand) $95 $190 $190 Tier 5 (Specialty Tier) 25% of the 25% of the 25% of the 30
Keystone 65 Select Rx (HMO) Keystone 65 Preferred Keystone 65 Preferred Rx (HMO) Standard Mail Order Cost-Sharing One- Month Supply Two- Month Supply Three- Month Supply One- Month Supply Two- Month Supply Three- Month Supply $4 $8 $8 $3 $6 $6 $10 $20 $20 $8 $16 $16 $45 $90 $90 $45 $90 $90 $95 $190 $190 $95 $190 $190 25% of the 25% of the 25% of the 33% of the 33% of the 33% of the 31
Keystone 65 Basic Rx (HMO) Keystone 65 Select 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 $2,960. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, 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 $4,700, you pay the greater of: 5% of the, or $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. 32
Keystone 65 Select Rx (HMO) 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. Keystone 65 Preferred Keystone 65 Preferred Rx (HMO) 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 $2,960. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, which is the end of the coverage gap. Not everyone will enter the 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 $2,960. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, 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 $4,700, you pay the greater of: 5% of the, or $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the, or $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. 33
Keystone 65 Basic Rx (HMO) Keystone 65 Select Optional Benefits (you must pay an extra premium each month for these benefits) Package 1: Choice Program Benefits include: Preventive Dental Eye Exams Eyewear Hearing Exams Hearing Aids Benefits include: Preventive Dental Eye Exams Eyewear Hearing Exams Hearing Aids How much is the monthly premium? Additional $7.00 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. Additional $7.00 per month. You must keep paying your Medicare Part B premium and your $0 or $25 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? No. There is no limit to how much our plan will pay for benefits in this package. No. There is no limit to how much our plan will pay for benefits in this package. 34
Keystone 65 Select Rx (HMO) Keystone 65 Preferred Keystone 65 Preferred Rx (HMO) Optional Benefits (you must pay an extra premium each month for these benefits) Benefits include: Preventive Dental Eye Exams Eyewear Hearing Exams Hearing Aids Additional $7.00 per month. You must keep paying your Medicare Part B premium and your $25 or $64 monthly plan premium. This package does not have a deductible. No. There is no limit to how much our plan will pay for benefits in this package. 35
Premium/Cost-Sharing Table If you have any questions about this plan, please call 877-393-6733 (TTY/TDD 711). Keystone 65 Preferred (HMO): Keystone 65 Select (HMO): If You Live In... And You Have... Keystone 65 Preferred Medical Only (HMO) Keystone 65 Preferred Rx (HMO) Per month. In addition, you must keep paying your Medicare Part B premium. Chester, Delaware, or Montgomery County $194 $263 Bucks or Philadelphia County $135 $190 If You Live In... Chester, Delaware, or Montgomery County And You Have... Keystone 65 Select Medical Only (HMO) Keystone 65 Select Rx (HMO) Keystone 65 Select Medical Only (HMO) with Optional Supplemental Benefits Keystone 65 Select Rx (HMO) with Optional Supplemental Benefits Per month. In addition, you must keep paying your Medicare Part B premium. $25 $64 $32 $71 Bucks or Philadelphia County $0 $25 $7 $32 Keystone 65 Basic Rx (HMO): If You Live In... And You Have... Keystone 65 Basic Rx (HMO) Keystone 65 Basic Rx (HMO) with Optional Supplemental Benefits Per month. In addition, you must keep paying your Medicare Part B premium. Bucks or Philadelphia County $0 $7 36
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PO Box 7799 Philadelphia, PA 19101-7799 www.ibxmedicare.com For more information... For updated information regarding plan providers, visit our website at www.ibxmedicare.com, or call the Member Help Team at 1-800-645-3965 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 voicemail. If you are not yet a member and have questions, please call 1-877-393-6733 or TTY/TDD 711, seven days a week, 8 a.m. to 8 p.m. Keystone 65 HMO is a HMO plan with a Medicare contract. Enrollment in Keystone 65 HMO depends on contract renewal. Benefits underwritten or administered by Keystone Health Plan East, a subsidiary of Independence Blue Cross independent licensees of the Blue Cross and Blue Shield Association. H3952 KS6414 (10/14)