Keystone 65 HMO 2021 - IBX
Keystone 65 HMO2021Summary of Benefits Keystone 65 Basic Rx HMOKeystone 65 Focus Rx HMO-POSKeystone 65 Select Medical-Only HMOKeystone 65 Select Rx HMOH3952Y0041 H3952 KS 89281 M
This booklet gives you a summary of what we coverand what you pay. It doesn’t list every service that wecover or list every limitation or exclusion. To get acomplete list of services we cover, call us and ask for theEvidence of Coverage or go online at www.ibxmedicare.com.This Summary of Benefits booklet gives you a summary of what Keystone 65 Basic Rx HMO,Keystone 65 Focus Rx HMO-POS, Keystone 65 Select Medical-Only HMO, and Keystone 65Select Rx HMO cover and what you pay.Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, Keystone 65 SelectMedical-Only HMO, and Keystone 65 Select Rx HMO are Medicare Advantage HMO(Health Maintenance Organization) plans. With an HMO plan, members choose a familydoctor, called a primary care physician (PCP), who provides the services they need.When they need specialized care, PCPs refer members to other doctors or health careproviders within the HMO provider network. Keystone 65 Focus Rx HMO-POS has aPoint-of-Service (POS) option. "Point-of-service" means you can use providers outside theplan's network for an additional cost. Members pay less if they use doctors, hospitals,and other health care providers that belong to the plan’s network. If you choose to see adoctor or specialist out of network, you may pay a higher cost-share except in the case ofan emergency.If you want to compare our plans with other available Medicare health plans, ask the otherplan(s) for their Summary of Benefits booklet. Or, use the Medicare Plan Finder atwww.medicare.gov. If you want to know more about the coverage and costs of OriginalMedicare, look in your current “Medicare and You” handbook. View it online atwww.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 of this booklet M onthly Premium and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits P rescription Drug Benefits for Keystone 65 Basic Rx, Keystone 65 Focus Rx,and Keystone 65 Select RxWho can join?To join Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, Keystone 65 SelectMedical-Only HMO, or Keystone 65 Select Rx HMO, you must be entitled to MedicarePart A, be enrolled in Medicare Part B, and live in our service area. Our service areaincludes the following counties in Pennsylvania: Bucks, Chester, Delaware, Montgomery,and Philadelphia.
Which doctors, hospitals, and pharmacies can I use?Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, Keystone 65 SelectMedical-Only HMO, and Keystone 65 Select Rx HMO have networks of doctors, hospitals,pharmacies, and other providers. Keystone 65 Basic Rx HMO, Keystone 65 SelectMedical-Only HMO, and Keystone 65 Select Rx HMO: If you use providers that are not inour networks, the plans may not pay for the services. With Keystone 65 Focus Rx HMOPOS, if you choose to see a doctor or specialist out of network, you may pay a highercost-share except in the case of an emergency.Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Keystone 65Select Rx HMO cover Part D drugs. In addition, the plans cover Part B drugs, such aschemotherapy and some other drugs administered by your provider. You can see ourcomplete plan Formulary (List of Covered Drugs) and any restrictions on our website:www.ibxmedicare.com.Keystone 65 Select Medical-Only HMO covers Part B drugs, including chemotherapyand some other drugs administered by your provider. However, this plan does not coverPart D prescription drugs.Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Keystone 65Select Rx HMO have a preferred pharmacy network; cost-sharing for drugs mayvary depending on the pharmacy you use. To view our lists of network providers andpharmacies (Provider/Pharmacy Directory), please visit www.ibxmedicare.com.1
Monthly Plan PremiumKeystone 65 Basic Rx HMOAnd You Have.Keystone 65 Basic Rx HMOIf You Live In.You Pay.Chester, Delaware, orMontgomery County 0Bucks or PhiladelphiaCounty 0Keystone 65 Focus Rx HMO-POSAnd You Have.Keystone 65 Focus Rx HMO-POSIf You Live In.You Pay.2Chester, Delaware, orMontgomery County 15Bucks or PhiladelphiaCounty 0
Keystone 65 Select Rx HMOAnd You Have.Keystone 65 Select Rx HMOIf You Live In.You Pay.Chester, Delaware, orMontgomery County 82.50Bucks or PhiladelphiaCounty 56.50Keystone 65 Select Medical-Only HMOAnd You Have.Keystone 65 Select Medical-Only HMOIf You Live In.You Pay.Chester, Delaware, orMontgomery County 49.50Bucks or PhiladelphiaCounty 34.503
Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSDeductibleThis plan does not have a deductible forcovered medical services or for PartD prescription drugs.This plan does not have a deductible forcovered medical services or for PartD prescription drugs.Maximum Out-of-Pocket 7,550 each year 6,500 each yearOur plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.Our plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.The Point-of-Service annualmaximum is 1,000.(the amounts you pay for yourpremium, Part D prescriptiondrugs, and some medicalservices do not count towardyour maximum out-of-pocket(MOOP) amount)Covered Medical and Hospital BenefitsKeystone 65Basic Rx HMOInpatient HospitalCoverage (1)Inpatient Hospital Stay Acute due to COVID-19diagnosis (1)Keystone 65Focus Rx HMO-POS 250 copayment per day for days 1through 7 per admission. 210 copayment per day for days 1through 6 per admission.You pay nothing per day for days 8and beyond per admission; 1,750maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period.You pay nothing per day for days 7and beyond per admission; 1,260maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period. 0 copayment 0 copaymentOut-of-Network: 20% coinsurance 200 copayment 200 copayment 350 copayment 325 copayment 350 copayment per stay 325 copayment per stayOut-of-Network: 20% coinsuranceOutpatient Hospital Coverage Ambulatory SurgicalCenter (1) Outpatient HospitalFacility (1) Observation Services4Services with a (1) may require prior authorization.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMOThis plan does not have a deductible forcovered medical services.This plan does not have a deductible forcovered medical services or for PartD prescription drugs. 4,900 each year 4,900 each yearOur plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.Our plan has a yearly coverage limitfor certain in-network benefits.Contact us for the services that apply.Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 250 copayment per day for days 1through 6 per admission. 250 copayment per day for days 1through 6 per admission.You pay nothing per day for days 7and beyond per admission; 1,500maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period.You pay nothing per day for days 7and beyond per admission; 1,500maximum copayment per admission.No copayment on day of discharge.Unlimited days per benefit period. 0 copayment 0 copayment 200 copayment 200 copayment 350 copayment 350 copayment 350 copayment per stay 350 copayment per stayServices with a (1) may require prior authorization.5
Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSDoctor’s Office Visits Primary Care Physician 0 copayment 0 copaymentOut-of-Network: 20% coinsurance Specialist 40 copayment 40 copaymentOut-of-Network: 20% coinsuranceYou pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.You pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service.Out-of-Network: 20% coinsuranceEmergency Care - coveredworldwide 90 copaymentNot waived if admitted 90 copaymentNot waived if admittedUrgently Needed Services covered worldwide 15 copayment in a retail clinicNot waived if admitted 10 copayment in a retail clinicNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 90 copayment per visit forWorldwide Urgent CoverageNot waived if admitted 90 copayment per visit forWorldwide Urgent CoverageNot waived if admittedEmergency and urgently needed careservices received outside the U.S. donot count toward the maximum outof-pocket amount (MOOP).Emergency and urgently needed careservices received outside the U.S. donot count toward the maximum outof-pocket amount (MOOP). 0 copayment applies to certaindiagnostic tests (e.g. home-based sleepstudies provided by a home healthagency; diagnostic mammograms thatresult from a preventive mammogram). 0 copayment applies to certaindiagnostic tests (e.g. home-based sleepstudies provided by a home healthagency; diagnostic mammograms thatresult from a preventive mammogram). Diagnostic RadiologyServices 45 or 200 copayment dependingon service 40 or 200 copayment dependingon service Lab ServicesYou pay nothingYou pay nothing Diagnostic Tests andProceduresYou pay nothingYou pay nothing Outpatient X-rays 45 copayment for routineradiology services 40 copayment for routineradiology servicesOut-of-Network: 20% coinsurancePreventive Care(e.g., flu vaccine, diabeticscreenings)Diagnostic Services (1), Laband Radiology Services (1),and X-rays (1)6Services with a (1) may require prior authorization.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 0 copayment 0 copayment 40 copayment 40 copaymentYou pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.You pay nothing. Please refer to theEvidence of Coverage for a completelisting of services.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service.If you receive a separate additionalnon-preventive evaluation and/orservice, a copayment will apply.The copayment amount depends onthe provider type or place of service. 90 copaymentNot waived if admitted 90 copaymentNot waived if admitted 15 copayment in a retail clinicNot waived if admitted 15 copayment in a retail clinicNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 40 copayment in an urgentcare centerNot waived if admitted 90 copayment per visit forWorldwide Urgent CoverageNot waived if admitted 90 copayment per visit forWorldwide Urgent CoverageNot waived if admittedEmergency and urgently needed careservices received outside the U.S. donot count toward the maximum outof-pocket amount (MOOP).Emergency and urgently needed careservices received outside the U.S. donot count toward the maximum outof-pocket amount (MOOP). 0 copayment applies to certaindiagnostic tests (e.g. home-based sleepstudies provided by a home healthagency; diagnostic mammograms thatresult from a preventive mammogram). 0 copayment applies to certaindiagnostic tests (e.g. home-based sleepstudies provided by a home healthagency; diagnostic mammograms thatresult from a preventive mammogram). 40 or 200 copayment dependingon service 40 or 200 copayment dependingon serviceYou pay nothingYou pay nothingYou pay nothingYou pay nothing 40 copayment for routineradiology services 40 copayment for routineradiology servicesServices with a (1) may require prior authorization.7
Keystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POSHearing Services Hearing Exam 40 copayment for Medicarecovered hearing exams 40 copayment for Medicarecovered hearing examsOut-of-Network: 20% coinsurance Hearing Aid8 10 copayment for routine nonMedicare-covered hearing examsonce every year 10 copayment for routine nonMedicare-covered hearing examsonce every year 699 copayment for a standarddigital hearing aid or 999copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; 3 hearing aidfittings per year; and up to 2 hearingaids every year, one hearing aidper ear. 699 copayment for a standarddigital hearing aid or 999copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; 3 hearing aidfittings per year; and up to 2 hearingaids every year, one hearing aidper ear.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 40 copayment for Medicarecovered hearing exams 40 copayment for Medicarecovered hearing exams 10 copayment for routine nonMedicare-covered hearing examsonce every year 10 copayment for routine nonMedicare-covered hearing examsonce every year 499 copayment for a standarddigital hearing aid or 799copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; 3 hearing aidfittings per year; and up to 2 hearingaids every year, one hearing aidper ear. 499 copayment for a standarddigital hearing aid or 799copayment for a premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; 3 hearing aidfittings per year; and up to 2 hearingaids every year, one hearing aidper ear.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.Routine hearing services and aidsare covered when provided by aTruHearing provider. Routinehearing services do not counttowards annual MOOP.9
Dental ServicesKeystone 65Basic Rx HMOKeystone 65Focus Rx HMO-POS 40 copayment for non-routineMedicare-covered dental services ina specialist office 40 copayment for non-routineMedicare-covered dental services ina specialist officeOut-of-Network: 20% coinsurance10 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full mouth X-ray(panoramic) every three years; 2,000 allowance every year. 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full mouth X-ray(panoramic) every three years; 2,000 allowance every year.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.Member must use in-networkUnited Concordia dental providers.Member must use in-networkUnited Concordia dental providers.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 40 copayment for non-routineMedicare-covered dental services ina specialist office 40 copayment for non-routineMedicare-covered dental services ina specialist office 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full mouth X-ray(panoramic) every three years; 2,000 allowance every year. 0 copayment for routine nonMedicare-covered exam and cleaningevery six months; 0 copaymentfor 1 set of dental bitewing X-raysevery year, 1 periapical X-ray every3 years, and 1 full mouth X-ray(panoramic) every three years; 2,000 allowance every year.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.20% coinsurance for restorativeservices, endodontics, periodontics,and extractions; 40% coinsurancefor prosthodontics, other oral/maxillofacial surgery,and other services.Member must use in-networkUnited Concordia dental providers.Member must use in-networkUnited Concordia dental providers.11
Keystone 65Basic Rx HMOVision Services 40 copayment for Medicarecovered eye exams to diagnoseand treat diseases of the eye; 0 copayment for diabetic retinalexam; 0 copayment for glaucomascreening; and 0 copaymentfor Medicare-covered eyeglassesor contact lenses aftercataract surgery.Keystone 65Focus Rx HMO-POS 40 copayment for Medicarecovered eye exams to diagnoseand treat diseases of the eye; 0 copayment for diabetic retinalexam; 0 copayment for glaucomascreening; and 0 copaymentfor Medicare-covered eyeglassesor contact lenses aftercataract surgery.Out-of-Network: 20% coinsurance 10 copay for one routine eye examevery year; 1 pair of eyeglass framesand lenses or one pair of contactlenses are covered every year.If eyewear is purchased from theDavis Vision Collection, the eyeglassframes and lenses are covered in full. 200 plan allowance every yearon eyewear (glasses and lenses)purchased through Visionworks; 150 plan allowance every yearfor all other eyewear (glasses andlenses) purchased through DavisVision; 150 allowance every yearfor contact lenses in lieu of routineeyewear (frames and lenses).Eyewear does not include lensoptions, such as tints, progressives,Transitions lenses, polish, andinsurance. Routine vision services(exam and eyewear) do not counttowards the annual MOOP.12 10 copay for one routine eye examevery year; 1 pair of eyeglass framesand lenses or one pair of contactlenses are covered every year.If eyewear is purchased from theDavis Vision Collection, the eyeglassframes and lenses are covered in full. 200 plan allowance every yearon eyewear (glasses and lenses)purchased through Visionworks; 150 plan allowance every yearfor all other eyewear (glasses andlenses) purchased through DavisVision; 150 allowance every yearfor contact lenses in lieu of routineeyewear (frames and lenses).Eyewear does not include lensoptions, such as tints, progressives,Transitions lenses, polish, andinsurance. Routine vision services(exam and eyewear) do not counttowards the annual MOOP.
Keystone 65Select Medical-Only HMOKeystone 65Select Rx HMO 40 copayment for Medicarecovered eye exams to diagnoseand treat diseases of the eye; 0 copayment for diabetic retinalexam; 0 copayment for glaucomascreening; and 0 copaymentfor Medicare-covered eyeglassesor contact lenses aftercataract surgery. 40 copayment for Medicarecovered eye exams to diagnoseand treat diseases of the eye; 0 copayment for diabetic retinalexam; 0 copayment for glaucomascreening; and 0 copaymentfor Medicare-covered eyeglassesor contact lenses aftercataract surgery. 10 copay for one routine eye examevery year; 1 pair of eyeglass framesand lenses or one pair of contactlenses are covered every year.If eyewear is purchased from theDavis Vision Collection, the eyeglassframes and lenses are covered in full. 200 plan allowance every yearon eyewear (glasses and lenses)purchased through Visionworks; 150 plan allowance every yearfor all other eyewear (glasses andlenses) purchased through DavisVision; 150 allowance every yearfor contact lenses in lieu of routineeyewear (frames and lenses).Eyewear does not include lensoptions, such as tints, progressives,Transitions lenses, polish, andinsurance. Routine vision services(exam and eyewear) do not counttowards the annual MOOP. 10 copay for one routine eye examevery
Keystone 65 Basic Rx HMO, Keystone 65 Focus Rx HMO-POS, and Keystone 65 Select Rx HMO have a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy you use. To view our lists of network providers and pharmacies (Provider
Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO have networks of doctors, hospitals, pharmacies, and other providers. Keystone 65 Basic Rx HMO, Keystone 65 Liberty Medical-Only HMO, Keystone 65 Select Medical-Only HMO, and Keystone 65 Select Rx HMO: If you use providers that are not in
Medical-Only HMO and Keystone 65 Preferred Rx HMO cover and what you pay. Keystone 65 Preferred Medical-Only HMO and Keystone 65 Preferred Rx HMO are Medicare Advantage HMO (Health Maintenance Organization) plans. With an HMO plan, members choose a family doctor, called a primary c
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 providers that are not in our network, we may not pay for these services. Keystone 65 Preferred Rx HMO also has a preferred pharmacy network; cost-sharing for drugs may vary depending on the
Keystone 65 Preferred Medical-Only HMO and Keystone . 65 Preferred Rx HMO are Medicare Advantage HMO (Health Maintenance Organization) plans. With an HMO plan, members choose a family doctor, called a primary care physician (PCP), who provides the services they need. Whe
Keystone 65 Select Rx HMO Keystone 65 Preferred Rx HMO Personal Choice 65SM Rx PPO 2020 Utilization Management Criteria: Prior Authorization PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
8 Medical with Rx MEDICARE ADVANTAGE PLANS 0 0 Benefit & Cost Comparison IN THIS SECTION: 1Quarterly OTC allowance does not carry over.The maximum out-of-pocket for 2021 is 7,550 for Keystone 65 Basic, 6,500 for Keystone 65 Focus, and 4,900 for Keystone 65 Select. *All Keystone 65 Basic, Keystone 65 Pre
Para afiliados a Health Net Seniority Plus (HMO)*, Health Net Healthy Heart (HMO), Health Net Ruby Select (HMO), Health Net Gold Select (HMO), Health Net Jade (HMO SNP) y Health Net Seniority Plus (Employer HMO). Su examen de la vista de rutina está cubierto como un beneficio médico básico a través de su plan médico.
Cambridge Manuals in Archaeology is a series of reference handbooks designe fodr an international audience of upper-level undergraduate and graduate students and , professional archaeologist ands archaeologica l scientist isn universities, museums, research laboratorie and fields units. Each book include a surve oysf current archaeological practice alongside essential referenc on contemporare .
