Keystone 65 HMO 2020 - IBX

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Keystone 65 HMO2020Summary of BenefitsEffective January 1, 2020 through December 31, 2020 Keystone 65 Preferred Medical-Only HMO Keystone 65 Preferred Rx HMOH3952Y0041 H3952 KS M 20 76201 Accepted 9/2/2019

This booklet gives you a summary of what we cover andwhat you pay. It doesn’t list every service that we coveror list every limitation or exclusion. To get a completelist 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 PreferredMedical-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 areMedicare Advantage HMO (Health Maintenance Organization) plans. With an HMOplan, members choose a family doctor, called a primary care physician (PCP), whoprovides the services they need. When they need specialized care, PCPs refer membersto other doctors or health care providers within the HMO provider network.Which doctors, hospitals, and pharmacies can I use?Keystone 65 Preferred Medical-Only HMO and Keystone 65 Preferred Rx HMO have anetwork of doctors, hospitals, pharmacies, and other providers. If you use the providers thatare not in our network, we may not pay for these services. Keystone 65 Preferred Rx HMOalso has a preferred pharmacy network; cost-sharing for drugs may vary depending on thepharmacy you use. To view our list of network providers and pharmacies (Provider/PharmacyDirectory), please visit www.ibxmedicare.com.Keystone 65 Preferred Rx HMO covers Part D drugs. In addition, the plan coversPart B drugs such as chemotherapy and some other drugs administered by your provider.You can see our complete plan Formulary (List of Covered Drugs) and any restrictions onour website, www.ibxmedicare.com.Keystone 65 Preferred Medical-Only HMO covers Part B drugs, including chemotherapy andsome other drugs administered by your provider. However, this plan does not cover Part Dprescription drugs.If you want to compare our plans with other available Medicare health plans, ask theother plan(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 Original Medicare, look inyour current “Medicare and You” handbook. View it online at www.medicare.gov or geta 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 Monthly Premium, Deductible, Limits on How Much You Pay forCovered ServicesMonthly Plan PremiumKeystone 65 Preferred HMO Covered Medical and Hospital BenefitsAnd You Have. Prescription Drug Benefits for Keystone 65 Preferred Rx HMOKeystone 65 PreferredMedical-Only HMOWho can join?To join Keystone 65 Preferred Medical-Only HMO or Keystone 65 Preferred Rx HMO,you must be entitled to Medicare Part A, be enrolled in Medicare Part B,and live in our service area.Our service area includes the following counties in Pennsylvania: Bucks, Chester,Delaware, Montgomery, and Philadelphia.If You Live In.Keystone 65 Preferred Rx HMOYou Pay.Chester, Delaware, orMontgomery CountyBucks or Philadelphia County 194 256 178 2281

Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMODeductibleThis plan does not have a deductiblefor covered medical services.This plan does not have a deductiblefor covered medical services.This plan does not have a deductiblefor Part D prescription drugs.Maximum Out-of-Pocket(the amounts you payfor your premium, Part Dprescription drugs and somemedical services do notcount toward your maximumout-of-pocket (MOOP)amount) 4,000 each year 4,000 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 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMO 225 copayment per day for days 1through 6 per admission 225 copayment per day for days 1through 6 per admissionYou pay nothing per day for days 7and beyond per admission. No copayment on day of discharge.You pay nothing per day for days7 and beyond per admission. Nocopayment on day of discharge. 1,350 maximum copaymentper admission 1,350 maximum copaymentper admissionUnlimited days per benefit periodUnlimited days per benefit periodOutpatient Hospital Coverage Ambulatory SurgicalCenter (1) Outpatient HospitalFacility (1) Observation ServicesKeystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMOPreventive Care(e.g., flu vaccine, diabeticscreenings)You pay nothingPlease refer to the Evidence ofCoverage for a complete listing ofservices. If you receive a separateadditional non-preventive evaluationand/or service, a copayment willapply. The copayment amountdepends on the provider type orplace of service.You pay nothingPlease refer to the Evidence ofCoverage for a complete listingof services. If you receive a separateadditional non-preventive evaluationand/or service, a copayment willapply. The copayment amountdepends on the provider type orplace of service.Emergency Care —covered worldwide 90 copaymentNot waived if admitted 90 copaymentNot waived if admitted 5 copayment in a retail clinicNot waived if admitted 5 copayment in a retail clinicNot waived if admitted 40 copayment in an urgent carecenterNot waived if admitted 40 copayment in an urgent carecenterNot waived if admitted 90 copayment per visit outside ofU.S.Not waived if admitted 90 copayment per visit outside ofU.S.Not waived if admitted Diagnostic RadiologyServices Lab Services 40 or 150 copayment dependingon service 40 or 150 copayment dependingon serviceYou pay nothingYou pay nothing Diagnostic Tests andProcedures Outpatient X-raysYou pay nothingYou pay nothing 40 copayment for routine radiologyservices 40 copayment for routine radiologyservicesWorldwide copayment outsidethe U.S. does not counttowards the annual MOOPCovered Medical and Hospital BenefitsInpatient Hospital Coverage(1)Covered Medical andHospital Benefits (cont.) 125 copayment 125 copayment 350 copayment 350 copayment 350 copayment per stay 350 copayment per stay 0 copayment per visit for aPreferred primary care physician 0 copayment per visit for aPreferred primary care physician 5 copayment per visit for aStandard primary care physician 5 copayment per visit for aStandard primary care physician 40 copayment 40 copaymentUrgently Needed Services —covered worldwideWorldwide copayment outsidethe U.S. does not counttowards the annual MOOPDiagnostic Services(1), Laband Radiology Services(1),and X-raysDoctor’s Office Visits Primary Care Physician Specialist2Services with a (1) may require prior authorization.Services with a (1) may require prior authorization.3

Covered Medical andHospital Benefits (cont.)Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMODental ServicesHearing Services Hearing Exam Hearing Aid4Covered Medical andHospital Benefits (cont.) 40 copayment for Medicarecovered hearing exams 40 copayment for Medicarecovered hearing exams 10 copayment for routinenon-Medicare-covered hearingexams once every year. 10 copayment for routinenon-Medicare-covered hearingexams once every year. 499 copayment standard digitalhearing aid or 799 copaymentpremium digital hearing aid peryear, per ear; 3 hearing aid fittingsper year; up to 2 hearing aids everyyear, one hearing aid per ear. 499 copayment standard digitalhearing aid or 799 copaymentpremium digital hearing aid peryear, per ear; 3 hearing aid fittingsper year; up to 2 hearing aids everyyear, one hearing aid per ear.Routine hearing services and aidsare covered when provided bya TruHearing provider. Routinehearing services do not counttowards annual MOOPRoutine hearing services and aidsare covered when provided bya TruHearing provider. Routinehearing services do not counttowards annual MOOPKeystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMO 40 copayment forMedicare-covered dental servicesin a specialist office 40 copayment forMedicare-covered dental servicesin a specialist office 10 copayment for routinenon-Medicare-covered exam andcleaning every six months; 0 copay for 1 set of dentalbite-wing X-rays every year.Full mouth X-rays (panoramic) notcovered; Comprehensive dentalservices not covered. Routine dentalservices do not count toward theannual MOOP. 10 copayment for routinenon-Medicare-covered exam andcleaning every six months; 0 copay for 1 set of dentalbite-wing X-rays every year.Full mouth X-rays (panoramic) notcovered; Comprehensive dentalservices not covered. Routine dentalservices do not count toward theannual MOOP.Services with a (1) may require prior authorization.5

Covered Medical andHospital Benefits (cont.)Vision ServicesKeystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMO 40 copayment for Medicare-coveredeye exams to diagnose and treatdiseases of the eye; 0 copaymentfor diabetic retinal exam; 0copayment for glaucoma screening; 0 copayment for Medicare-coveredeyeglasses or contact lenses aftercataract surgery 40 copayment for Medicare-coveredeye exams to diagnose and treatdiseases of the eye; 0 copaymentfor diabetic retinal exam; 0copayment for glaucoma screening; 0 copayment for Medicare-coveredeyeglasses or 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; Ifeyewear is purchased from theDavis Vision Collection the eyeglassframes and lenses are covered in full; 200 plan allowance every year oneyewear (glasses, lenses) purchasedthrough Visionworks; 150 planallowance every year for all othereyewear (glasses, lenses or contacts)purchased through Davis Vision;Eyewear does not include lens optionssuch as tints, progressives, transitionlenses, polish, and insurance. Routinevision services (exam and eyewear) donot count towards the annual MOOP. 10 copay for one routine eye examevery year; 1 pair of eyeglass framesand lenses or one pair of contactlenses are covered every year; Ifeyewear is purchased from theDavis Vision Collection the eyeglassframes and lenses are covered in full; 200 plan allowance every year oneyewear (glasses, lenses) purchasedthrough Visionworks; 150 planallowance every year for all othereyewear (glasses, lenses or contacts)purchased through Davis Vision;Eyewear does not include lens optionssuch as tints, progressives, transitionlenses, polish, and insurance. Routinevision services (exam and eyewear) donot count towards the annual MOOP.Covered Medical andHospital Benefits (cont.)Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMOMental Health Services Inpatient MentalHealth Care(2) 225 copayment per day for days 1through 6You pay nothing per day for days 7and beyond 225 copayment per day for days 1through 6You pay nothing per day for days 7and beyond 1,350 maximum copayment peradmission 1,350 maximum copayment peradmission190-day lifetime maximum in amental health facility190-day lifetime maximum in amental health facility Outpatient Therapy(Group and Individual) 40 copayment 40 copayment Outpatient SubstanceAbuse Services(Group and Individual) 40 copayment 40 copayment Partial Hospitalization(2) 40 copayment 40 copaymentYou pay nothing per day for days 1through 20 per admissionYou pay nothing per day for days 1through 20 per admission 150 copayment per day for days 21through 100 per admission 150 copayment per day for days 21through 100 per admission100 days per benefit period100 days per benefit periodPhysical Therapy(1) 20 copayment per visit 20 copayment per visitAmbulance(1) 150 copayment for a one-way tripNot waived if admitted 150 copayment for a one-way tripNot waived if admittedNon-emergency ambulance servicesrequire prior authorizationNon-emergency ambulance servicesrequire prior authorizationTransportationNot coveredNot coveredMedicare Part B Drugs(1)20% coinsurance for Part B drugssuch as chemotherapy drugs20% coinsurance for Part B drugssuch as chemotherapy drugsFor a description of the types ofdrugs available under Part B, seeyour Evidence of CoverageFor a description of the types ofdrugs available under Part B, seeyour Evidence of CoverageSkilled Nursing Facility(1)Services with a (1) may require prior authorization.6(2) Prior authorization is required by Magellan Behavioral Health.7

Prescription Drug Benefits (Part D)Part D Prescription Drug Benefits are available for members of Keystone 65 Preferred Rx HMO. This benefitis not available for members of Keystone 65 Preferred Medical-Only HMO.Keystone 65 PreferredMedical-Only HMOInitial Coverage StagePart D prescription drugs are notavailable with this plan.Keystone 65 PreferredRx HMOYou pay the following until your totalyearly drug costs reach 4,020.“Total yearly drug costs” are thetotal drug costs paid by both you andour Part D plan.You may get your drugs at networkretail pharmacies and mail-orderpharmacies.Cost-sharing may change dependingon the pharmacy you choose andwhen you move into each stageof your Part D benefits. You mayfill your prescriptions at either apreferred or standard pharmacy.Tier 1 and 2 prescriptions (whichinclude most generic drugs) will havelower copayments when you havethem filled at preferred pharmacies.For information, please reviewthe Keystone 65 Rx HMOEvidence of Coverage.Prescription Drug Benefits(Part D) (cont.)Retail Cost-sharing(what you pay at a pharmacylocation)Keystone SupplyThree-MonthSupplyPreferred Pharmacy 1 copayment 2 copayment 2 copaymentStandard Pharmacy 9 copayment 18 copayment 27 copaymentTier 1 (Preferred Generic Drugs)Part Dprescriptiondrugs are notavailable withthis plan.Keystone 65 PreferredRx HMOTier 2 (Generic Drugs)Preferred Pharmacy 9 copayment 18 copayment 18 copaymentStandard Pharmacy 20 copayment 40 copayment 60 copaymentPreferred Pharmacy 47 copayment 94 copayment 141 copaymentStandard Pharmacy 47 copayment 94 copayment 141 copaymentPreferred Pharmacy 100 copayment 200 copayment 300 copaymentStandard Pharmacy 100 copayment 200 copayment 300 copaymentPreferred Pharmacy33% coinsurance33% coinsurance33% coinsuranceStandard Pharmacy33% coinsurance33% coinsurance33% coinsuranceTier 3 (Preferred Brand Drugs)Tier 4 (Non-Preferred Drugs)Tier 5 (Specialty Drugs)Mail-Order Cost-sharing(what you pay when youorder a prescription by mail)Tier 1 (Preferred Generic Drugs)8Part Dprescriptiondrugs are notavailable withthis ly 1 copayment 2 copayment 2 copaymentTier 2 (Generic Drugs) 9 copayment 18 copayment 18 copaymentTier 3 (Preferred Brand Drugs) 47 copayment 94 copayment 94 copaymentTier 4 (Non-Preferred Drugs) 100 copayment 200 copayment 200 copaymentTier 5 (Specialty Drugs)33% coinsurance33% coinsurance33% coinsurance9

Other Medical BenefitsPrescription Drug Benefits(Part D) (cont.)Initial Coverage StageKeystone 65 PreferredMedical-Only HMOPart D prescription drugs are notavailable with this plan.Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMO Medical Condition 20 copayment per visit for conditiontreatment 20 copayment per visit for conditiontreatment Routine Foot Care(Medicare-covered) 20 copayment per visit forMedicare-covered routine care 20 copayment per visit forMedicare-covered routine care Routine Foot Care(non-Medicare-covered) 20 copayment per visit for nonMedicare-covered routine foot care(up to 6 visits each year) 20 copayment per visit for nonMedicare-covered routine foot care(up to 6 visits each year)Over-the-Counter(OTC) ItemsMost Medicare drug plans have acoverage gap (also called the “donuthole”). This means that there’s atemporary change in what you willpay for your drugs. The coverage gapbegins after the total yearly drug cost(including what our plan has paid andwhat you have paid) reaches 4,020. 30 allowance for over-the-counter(OTC) items. OTC allowance isprovided quarterly and does notcarry forward to the next quarterif not used. You must use our OTCvendor, Convey, to purchase OTCitems. Over-the-counter itemspurchased from pharmacies or otherretailers will NOT be covered. Onlyone order can be placed per quarter.Each order cannot exceed the 30quarterly allowance. 30 allowance for over-the-counter(OTC) items. OTC allowance isprovided quarterly and does notcarry forward to the next quarterif not used. You must use our OTCvendor, Convey, to purchase OTCitems. Over-the-counter itemspurchased from pharmacies or otherretailers will NOT be covered. Onlyone order can be placed per quarter.Each order cannot exceed the 30quarterly allowance.Telemedicine VisitsAfter you enter the coverage gap,you pay 25% of the plan’s cost forcovered brand-name drugs and25% of the plan’s cost for coveredgeneric drugs until your costs total 6,350, which is the end of thecoverage gap. Not everyone will enterthe coverage gap. 5 copayment for telemedicine visits.Telemedicine physicians are available24/7 365 days per year. MDLIVEmust be used for telemedicine visits.MDLIVE doctors are state-licensedphysicians. Telemedicine servicesrendered from other providers willnot be covered. 5 copayment for telemedicine visits.Telemedicine physicians are available24/7 365 days per year. MDLIVEmust be used for telemedicine visits.MDLIVE doctors are state-licensedphysicians. Telemedicine servicesrendered from other providers willnot be covered.Chiropractic Services Medical Condition 20 copayment per visit for spinalmanipulations 20 copayment per visit for spinalmanipulations Routine Care(non-Medicare-covered) 20 copayment per visit fornon-Medicare-covered routinechiropractic care (up to 6 visits eachyear) 20 copayment per visit fornon-Medicare-covered routinechiropractic care (up to 6 visits eachyear)No copayment for diabetic test stripsand glucose monitors. You must useour preferred vendors Accu-Chekand OneTouch for test strips andmonitors. Test strips and monitorsfrom other vendors will not becovered. No copayment for lancets,solutions, diabetic shoes and inserts.No copayment for diabetic test stripsand glucose monitors. You must useour preferred vendors Accu-Chekand OneTouch for test strips andmonitors. Test strips and monitorsfrom other vendors will not becovered. No copayment for lancets,solutions, diabetic shoes and inserts.Keystone 65 PreferredRx HMODuring this stage, the plan pays itsshare of the cost of your drugs andyou pay your share of the cost.You begin in this stage when you fillyour first prescription of the year.You stay in this stage until youryear-to-date “total drug costs”(your payments plus any Part Dplan’s payments) total 4,020.If you reside in a long-term carefacility, you pay the same as ata retail pharmacy. This plan hasa preferred pharmacy network;cost-sharing for drugs may varydepending on the pharmacy used.Podiatry ServicesYou may get drugs from an out-ofnetwork pharmacy at the same costas an in-network pharmacy.Coverage Gap StageCatastrophic CoverageStagePart D prescription drugs are notavailable with this plan.Part D prescription drugs are notavailable with this plan.After your yearly out-of-pocket drugcosts (including drugs purchasedthrough your retail pharmacy andthrough mail order) reach 6,350,you pay the greater of: 5% of the costs, or; 3.60 copayment for generic(including brand drugs tested asgeneric) and an 8.95 copaymentfor all other drugs10Diabetic SuppliesServices with a (1) may require prior authorization.11

Language Assistance ServicesPre-Enrollment ChecklistSpanish: ATENCIÓN: Si habla español, cuenta conservicios de asistencia en idiomas disponiblesde forma gratuita para usted. Llame al1-800-275-2583 (TTY: 711).Before making an enrollment decision, it is important that you fully understand our benefits andrules. If you have any questions, you can call and speak to a Member Help Team representative at1-800-

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

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