2022 Keystone 65 Preferred HMO Plan Information - IBX

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2022 Keystone 65 Preferred HMOPlan Information

Keystone 65 HMO2022Summary of BenefitsEffective January 1, 2022 through December 31, 2022 Keystone 65 Preferred Medical-Only HMO Keystone 65 Preferred Rx HMOH3952Y0041 H3952 KS 22 99147 M

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.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, Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits for Keystone 65 Preferred Rx 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 ourservice area.Our service area includes the following counties in Pennsylvania: Bucks, Chester,Delaware, Montgomery, and Philadelphia.

Which doctors, hospitals, and pharmacies can I use?Keystone 65 Preferred Medical-Only HMO and Keystone 65 Preferred Rx HMO have anetwork of doctors, hospitals, pharmacies, and other providers. If you use 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 covers Part Bdrugs such as chemotherapy and some other drugs administered by your provider. You cansee our complete plan Formulary (List of Covered Drugs) and any restrictions on our website,at 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.Monthly Plan PremiumKeystone 65 Preferred HMOAnd You Have.If You Live In.Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMOYou Pay.Chester, Delaware, orMontgomery County 187 258Bucks or Philadelphia County 178 2311

Keystone 65 PreferredMedical-Only HMODeductibleThis plan does not have a deductiblefor covered medical services.Keystone 65 PreferredRx HMOThis 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) 3,800 each year 3,800 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.Covered Medical and Hospital BenefitsKeystone 65 PreferredMedical-Only HMOInpatient HospitalCoverage (1)Inpatient Hospital Stay –Acute due to COVID-19diagnosis (1)Keystone 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 days 7 andbeyond per admission.No copayment on day of discharge. 1,350 maximum copaymentper admission 1,350 maximum copaymentper admissionUnlimited days per benefit periodUnlimited days per benefit period 0 copayment 0 copayment 350 copayment 350 copayment 350 copayment per stay 350 copayment per stay 0 copayment per visit 0 copayment per visit 40 copayment per visit 40 copayment per visitOutpatient Hospital Coverage O utpatient HospitalFacility (1) Observation ServicesDoctor’s Office Visits Primary Care Physician Specialist2Services with a (1) may require prior authorization.

Covered Medical andHospital Benefits (cont.)Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMOPreventive Care (1)(e.g., flu vaccine, diabeticscreenings)You pay nothingYou 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.Please 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 toinpatient hospital 90 copaymentNot waived if admitted toinpatient hospitalUrgently Needed Services —covered worldwide 5 copayment in a retail clinicNot waived if admitted 5 copayment in a retail clinicNot waived if admittedWorldwide copayment outsidethe U.S. does not count towardsthe annual MOOP 40 copayment in anurgent care centerNot waived if admitted 40 copayment in anurgent care centerNot waived if admitted 90 copayment per visitoutside of U.S.Not waived if admitted 90 copayment per visitoutside of U.S.Not waived if admittedDiagnostic Services, Laband Radiology Services, andX-rays 0 copayment applies to certaindiagnostic tests (e.g. homebased sleep studies provided by ahome health agency; diagnosticcolonoscopy that results from apreventive colonoscopy). 0 copayment applies to certaindiagnostic tests (e.g. homebased sleep studies provided by ahome health agency; diagnosticcolonoscopy that results from apreventive colonoscopy). D iagnostic RadiologyServices (1) 40 or 150 copayment dependingon service 40 or 150 copayment dependingon service Diagnostic procedures,tests, and lab services (1) 0 copayment 0 copayment Outpatient X-rays 40 copayment for routineradiology services 40 copayment for routineradiology services Therapeutic Radiology (1) 60 copayment 60 copayment R adiation for BreastCancer 0 copayment for members witha diagnosis of breast cancer 0 copayment for members witha diagnosis of breast cancerWorldwide copayment outsidethe U.S. does not count towardsthe annual MOOPServices with a (1) may require prior authorization.3

Covered Medical andHospital Benefits (cont.)Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMOHearing Services Hearing Exam Hearing Aid4 40 copayment for Medicarecovered hearing exams 40 copayment for Medicarecovered hearing exams 0 copayment for routinenon-Medicare-covered hearingexams once every year 0 copayment for routinenon-Medicare-covered hearingexams once every year 499 copayment for an advanceddigital hearing aid or 799copayment for premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; unlimitedhearing aid fittings per year; up to 2hearing aids every year, one hearingaid per ear. 499 copayment for an advanceddigital hearing aid or 799copayment for premium digitalhearing aid per year, per ear;premium includes a rechargeablehearing aid option; unlimitedhearing aid fittings per year; up to 2hearing aids every year, one hearingaid per ear.Routine hearing services and aidsare covered when provided bya TruHearing provider. Routinehearing services do not counttowards annual MOOP.Routine hearing services and aidsare covered when provided bya TruHearing provider. Routinehearing services do not counttowards annual MOOP.

Covered Medical andHospital Benefits (cont.)Dental ServicesKeystone 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 0 copayment for routinenon-Medicare-covered exam andcleaning every six months; 0 copayment for 1 set of dentalbitewing X-rays every year, 1periapical X-ray every 3 years,and 1 full-mouth X-ray (panoramic)every 3 years 0 copayment for routinenon-Medicare-covered exam andcleaning every six months; 0 copayment for 1 set of dentalbitewing X-rays every year, 1periapical X-ray every 3 years,and 1 full-mouth X-ray (panoramic)every 3 yearsComprehensive dental services notcovered. Routine dental services donot count toward the annual MOOP.Comprehensive dental services notcovered. Routine dental services donot count toward the annual MOOP.5

Covered Medical andHospital Benefits (cont.)Vision Services6Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMO 40 copayment for Medicare-coveredeye exams to diagnose and treatdiseases of the eye; 0 copayment fordiabetic retinal exam; 0 copayment for glaucomascreening; 0 copayment forMedicare-covered eyeglasses orcontact lenses after cataract surgery 40 copayment for Medicare-coveredeye exams to diagnose and treatdiseases of the eye; 0 copayment fordiabetic retinal exam; 0 copayment for glaucomascreening; 0 copayment forMedicare-covered eyeglasses orcontact lenses after cataract surgery 0 copay for one routine eye examevery year; contact lenses or one pairof eyeglass frames and lenses arecovered every year 0 copay for one routine eye examevery year; contact lenses or one pairof eyeglass frames and lenses arecovered every yearIf eyewear is purchased from theDavis Vision Collection the eyeglassframes and lenses are covered in full. 250 plan allowance every year oneyewear (glasses or lenses) purchasedthrough Visionworks; 150 planallowance every year for all othereyewear (glasses, lenses or contacts)purchased through Davis Vision; 150 allowance every year for contactlenses in lieu of routine eyewear(frames and lenses).If eyewear is purchased from theDavis Vision Collection the eyeglassframes and lenses are covered in full. 250 plan allowance every year oneyewear (glasses or lenses) purchasedthrough Visionworks; 150 planallowance every year for all othereyewear (glasses, lenses or contacts)purchased through Davis Vision; 150 allowance every year for contactlenses in lieu of routine eyewear(frames and lenses).Eyewear does not include lens optionssuch as tints, progressives, transitionlenses, polish, and insurance. Routinevision services (exam and eyewear) donot count towards the annual MOOP.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 I npatient MentalHealth Care (2) 225 copayment per dayfor days 1 through 6You pay nothing per dayfor days 7 and beyond 225 copayment per dayfor days 1 through 6You pay nothing per dayfor days 7 and beyond 1,350 maximum copaymentper admission 1,350 maximum copaymentper admission190-day lifetime maximum in amental health facility190-day lifetime maximum in amental health facility Outpatient Therapy (1)(Group and Individual) 40 copayment 40 copayment O utpatient SubstanceAbuse Services(Group and Individual) 40 copayment 40 copayment Partial Hospitalization (2) 40 copayment 40 copayment 0 copayment per day for days 1through 20 per admission 0 copayment per day for days 1through 20 per admission 188 copayment per day for days 21through 100 per admission 188 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 covered (offered under uniformflexibility, see page 12)Not covered (offered under uniformflexibility, see page 12)Medicare Part B Drugs (1)(Step therapy required forcertain Part B drugs)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 CoverageAmbulatory SurgicalServices (1) 125 copayment 125 copaymentSkilled Nursing Facility (1)Services with a (1) may require prior authorization.(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.Prescription Drug Benefits(Part D)Retail Cost-sharing(what you pay at a pharmacylocation)Keystone SupplyThree-MonthSupplyPreferred Pharmacy 0 copayment 0 copayment 0 copaymentStandard Pharmacy 9 copayment 18 copayment 27 copaymentPreferred 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 PharmacyInsulin: 35copayment*Insulin: 70copayment*Insulin: 105copayment*Standard PharmacyInsulin: 35copayment*Insulin: 70copayment*Insulin: 105copayment*Tier 1 (Preferred Generic Drugs)Part Dprescriptiondrugs are notavailable withthis plan.Keystone 65 PreferredRx HMOTier 2 (Generic Drugs)Tier 3 (Preferred Brand Drugs)Tier 3 (Insulin Savings Program)Tier 4 (Non-Preferred Drugs)Preferred Pharmacy 100 copayment 200 copayment 300 copaymentStandard Pharmacy 100 copayment 200 copayment 300 copaymentPreferred Pharmacy33% coinsurance33% coinsurance33% coinsuranceStandard Pharmacy33% coinsurance33% coinsurance33% coinsuranceTier 5 (Specialty Drugs)*Insulin copayment through the coverage gap for covered select insulins offered under the Insulin Savings Program.8

Prescription Drug Benefits(Part D) (cont.)Mail-Order Cost-sharing(what you pay when youorder a prescription by mail)Keystone Supply 0 copayment 0 copayment 0 copaymentTier 2 (Generic Drugs) 9 copayment 18 copayment 18 copaymentTier 3 (Preferred Brand Drugs) 47 copayment*Insulin 35 copayment 94 copayment*Insulin 70 copayment 94 copayment*Insulin 70 copaymentTier 4 (Non-Preferred Drugs) 100 copayment 200 copayment 200 copaymentTier 5 (Specialty Drugs)33% coinsuranceTier 1 (Preferred Generic Drugs)Initial Coverage StagePart Dprescriptiondrugs are notavailable withthis plan.Keystone 65 PreferredRx HMOPart Dprescriptiondrugs are notavailable withthis plan.33% coinsuranceThree-MonthSupply33% coinsuranceYou pay the following until your total yearly drugcosts reach 4,430. “Total yearly drug costs”are the total drug costs paid by both you and ourPart D plan.You may get your drugs at network retail pharmaciesand mail-order pharmacies.Cost-sharing may change depending on the pharmacyyou choose and when you move into each stage ofyour Part D benefits. You may fill your prescriptionsat either a preferred or standard pharmacy.Tier 1 and 2 prescriptions (which include mostgeneric drugs) will have lower copayments when youhave them filled at preferred pharmacies.For information, please review the Keystone 65 RxHMO Evidence of Coverage.9

Prescription Drug Benefits(Part D) (cont.)Initial Coverage StageKeystone 65 PreferredMedical-Only HMOPart D prescription drugs are notavailable with this plan.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 payments) total 4,430. If youreside in a long-term care facility,you pay the same as at a retailpharmacy. This plan has a preferredpharmacy network; cost-sharing fordrugs may vary depending on thepharmacy used.You may get drugs from an out-ofnetwork pharmacy at the same costas an in-network pharmacy.Coverage Gap StagePart D prescription drugs are notavailable with this plan.Most 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 4,430.After 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 7,050, which is the end of thecoverage gap. Not everyone will enterthe coverage gap.Catastrophic CoverageStagePart 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 7,050,you pay the greater of: 5% of the costs, or; 3.95 copayment for generic(including brand drugs tested asgeneric) and a 9.85 copaymentfor all other drugs10

Other Medical BenefitsKeystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMOPodiatry Services Medical Condition(Medicare-coveredpodiatry care) 20 copayment per visit forcondition treatment 20 copayment per visit forcondition treatment 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) Items 30 allowance for over-the-counter(OTC) items. OTC allowance isprovided quarterly and does not carryforward to the next quarter if not used.You must use our OTC vendor card topurchase OTC items at participatingretailers. Over-the-counter itemspurchased from non-participatingretailers will NOT be covered. OTCitems can also be ordered with theIBX Care Card via website, phoneor catalog. 30 allowance for over-the-counter(OTC) items. OTC allowance isprovided quarterly and does not carryforward to the next quarter if not used.You must use our OTC vendor card topurchase OTC items at participatingretailers. Over-the-counter itemspurchased from non-participatingretailers will NOT be covered. OTCitems can also be ordered with theIBX Care Card via website, phoneor catalog.Telemedicine Visits 0 copayment for doctor visits focusedon non-urgent medical conditions; 0 copayment for behavioralhealth visits focused on therapy andcounseling services. Telemedicinephysicians are available 24/7, 365days per year. MDLIVE must be usedfor telemedicine visits. MDLIVEdoctors are state-licensed physicians.Telemedicine services rendered fromother providers will not be covered. 0 copayment for doctor visits focusedon non-urgent medical conditions; 0 copayment for behavioralhealth visits focused on therapy andcounseling services. Telemedicinephysicians are available 24/7, 365days per year. MDLIVE must be usedfor telemedicine visits. MDLIVEdoctors are state-licensed physicians.Telemedicine services rendered fromother providers will not be covered. 20 copayment per visit for spinalmanipulations 20 copayment per visit for spinalmanipulations 20 copayment per visit for nonMedicare-covered routine chiropracticcare (up to 6 visits each year) 20 copayment per visit for nonMedicare-covered routine chiropracticcare (up to 6 visits each year) 20 copayment per visit, up to 12 visitsper year; 8 additional if determined thatprogress is made 20 copayment per visit(up to 6 visits each year) 20 copayment per visit, up to 12 visitsper year; 8 additional if determined thatprogress is made 20 copayment per visit(up to 6 visits each year) 20 copayment (up to 6 visits per year) 20 copayment (up to 6 visits per year)Chiropractic Services Medical Condition(Medicare-covered) Routine Care*(non-Medicare-covered)Acupuncture Medical Condition(Medicare-covered) Routine Care†(non-Medicare-covered)*Routine visits does not count toward MOOP.† Routine services must have one of the following conditions: headache (migraine and tension), post-operativenausea and vomiting, chemotherapy-induced nausea and vomiting, low back pain, chronic neck pain, or pain fromosteoarthritis of the knee and hip.11

Uniform Flexibility BenefitsVital Care ProgramTransportation Services12Keystone 65 PreferredMedical-Only HMOKeystone 65 PreferredRx HMOThe Vital Care Program isdesigned to help memberswho often need to see severalspecialists more than once ayear to improve their overallhealth and well-being. The VitalCare Program can help makethese visits more affordableand encourage members tosee their physicians regularly.Members must have bothdiabetes and congestiveheart failure to participate.The Vital Care Program isdesigned to help memberswho often need to see severalspecialists more than once ayear to improve their overallhealth and well-being. The VitalCare Program can help makethese visits more affordableand encourage members tosee their physicians regularly.Members must have bothdiabetes and congestiveheart failure to participate. 10 copayment forcardiology specialist visits 10 copayment forcardiology specialist visits 10 copayment forendocrinology specialist visits 10 copayment forendocrinology specialist visits 5 copayment for Medicarecovered podiatry visits 5 copayment for Medicarecovered podiatry visits 5 copayment for routinepodiatry visits, up to 6 visitsper year 5 copayment for routinepodiatry visits, up to 6 visitsper yearCardiology, endocrinology,and podiatry visits applytoward your maximumout-of-pocket amount.Cardiology, endocrinology,and podiatry visits applytoward your maximumout-of-pocket amount.Routine podiatry visits do notapply toward your MOOP.Routine podiatry visits do notapply toward your MOOP. 0 copayment 0 copayment12 one-way trips per year toapproved medical facilities12 one-way trips per year toapproved medical facilitiesMembers must have bothdiabetes and congestiveheart failure to receive thetransportation benefit.Members must have bothdiabetes and congestiveheart failure to receive thetransportation benefit.

Insulin Savings Program BenefitsKeystone 65 PreferredMedical-Only HMOGrocery BenefitMeals ProgramKeystone 65 PreferredRx HMO 0 copayment 0 copaymentGrocery boxes containing foodand produce will be providedby United by Blue for amaximum of 4 weeks peryear, per member.Grocery boxes containing foodand produce will be providedby United by Blue for amaximum of 4 weeks peryear, per member.Members must have bothdiabetes and depression to beeligible for the grocery benefit.Members must have bothdiabetes and depression to beeligible for the grocery benefit. 0 copayment 0 copayment3 meals per day, 7 days perweek, from MANNA3 meals per day, 7 days perweek, from MANNAMeals received up to 4 weeks,2 times per yearMeals received up to 4 weeks,2 times per yearTwo groups are eligible. Group1: must have a new diagnosisof colorectal, endometrial,breast (male/female), lung,or prostate cancer. Group 2:must have both diabetes andcongestive heart failure.*Two groups are eligible. Group1: must have a new diagnosisof colorectal, endometrial,breast (male/female), lung,or prostate cancer. Group 2:must have both diabetes andcongestive heart failure.**Group 2 member meals will be provided after discharge to the home following an inpatient acute hospital,skilled nursing facility, long-term acute care facility, acute rehabilitation facility, or rehabilitation facility stay.13

Pre-Enrollment ChecklistBefore 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 at1-800-645-3965 (TTY/TDD: 711).Understanding the BenefitsReview the full list of benefits found in the Evidence of Coverage (EOC), especially forthose services for which you routinely see a doctor. Visit www.ibxmedicare.com or call1-800-645-3965 (TTY/TDD: 711) to view a copy of the EOC.Review the provider directory (or ask your doctor) to make sure the doctors you seenow are in the network. If they are not listed, it means you will likely have to select anew doctor.Review the pharmacy directory to make sure the pharmacy you use for any prescriptionmedicines is in the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your prescriptions.Understanding Important RulesIn addition to your monthly plan premium, you must continue to pay your Medicare Part Bpremium. This premium is normally taken out of your Social Security check each month.Benefits, premiums, and/or copayments/coinsurance may change on January 1, 2023.Except in emergency or urgent situations, we do not cover services by out-of-networkproviders (doctors who are not listed in the provider directory).14

For more informationFor 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 April 1 through September 30, your callmay 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. Please note that on weekends and holidays from January 1 throughSeptember 30, your call may be sent to voicemail. By calling this number you will be directed to alicensed sales agent.Keystone 65 offers HMO plans with a Medicare contract. Enrollment in Keystone 65 MedicareAdvantage plans depends on contract renewal.Benefits underwritten by Keystone Health Plan East, a subsidiary of Independence Blue Cross —independent licensees of the Blue Cross and Blue Shield Association.Magellan Behavioral Health, Inc., an independent company, manages mental health andsubstance abuse benefits for most Independence Blue Cross members.Quartet is a separate and independent company that provides mental health services forIndependence Blue Cross members.TruHearing is a registered trademark of TruHearing, Inc., an independent company.Vision benefits are underwritten by Keystone Health Plan East and administered by Davis Vision,an independent company.An affiliate of Independence Blue Cross has a financial interest in Visionworks, an independent company.Dental benefits are underwritten by Keystone Health Plan East and administered by UnitedConcordia Companies, Inc., an independent company.FutureScripts Secure is an independent company that provides pharmacy benefit management services.Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.The Independence Blue Cross Over-the-counter benefit is underwritten by Keystone Health PlanEast and is administered by InComm, an independent company.Telemedicine is provided by MDLIVE, an independent company.Strive Health, LLC is an independent company that administers kidney care management to selectmembers of Independence Blue Cross Medicare Advantage plans.Roundtrip is an independent company that administers our transportation benefit.United by Blue is an independent company that administers our grocery delivery benefit.MANNA is an independent company and administers our meals program benefit.To receive this document in an alternate format such as Braille, large print, or audio, please call1-877-393-6733 (non-members) (by calling this number you will be directed to a licensed salesagent) or 1-800-645-3965 (members) (TTY/TDD: 711).This information is not a complete description of benefits. Contact 1-877-393-6733 orTTY/TDD: 711 for more information.15

Language Assistance ServicesSpanish: ATENCIÓN: Si habla español, cuenta conservicios de asistencia en idiomas disponiblesde forma gratuita para usted. Llame al1-800-275-2583 (TTY: 711).Chinese: �的语言协助服务。致电 1-800-275-2583。Korean: 안내사항: 한국어를 사용하시는 경우, 언어지원 서비스를 무료로 이용하실 수 있습니다.1-800-275-2583 번으로 전화하십시오.Portuguese: ATENÇÃO: se você fala português,encontram-se disponíveis serviços gratuitos deassistência ao idioma. Ligue para 1-800-275-2583.ુ રાતી બોલતા હો, તો િન: ુ Gujarati: ૂચના: જો તમે જભાષા સહાય સેવાઓ તમારા માટ લ છે .1-800-275-2583 કોલ કરો.Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôisẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí chobạn. Hãy gọi 1-800-275-2583.Russian: ВНИМАНИЕ: Если вы говорите по-русски,то можете бесплатно воспользоваться услугамиперевода. Тел.: 1-800-275-2583.Polish UWAGA: Jeżeli mówisz po polsku, możeszskorzystać z bezpłatnej pomocy językowej. Zadzwońpod numer 1-800-275-2583.Italian: ATTENZIONE: Se lei parla italiano, sonodisponibili servizi di assistenza linguistica gratuiti.Chiamare il numero 1-800-275-2583.Arabic: فإن خدمات المساعدة اللغوية ، إذا كنت تتحدث اللغة العربية : ملحوظة .1-800-275-2583 اتصل برقم . متاحة لك بالمجان French Creole: ATANSYON: Si w pale KreyòlAyisyen, gen sèvis èd pou lang ki disponib gratis pouou. Rele 1

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

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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

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.

My Avatar - Financial Eligibility Guide . 10 Baycare Medical Group 44 HMO Insurance 11 BC Freedom Blue MDC HMO 42 HMO Insurance (MDC) 12 Benefit and Risk Management Services 45 HMO Insurance 13 Benesight 46 HMO Insurance 14 Blue Cross of CA 4 HMO Insurance (MDC) 15 Blue Shield Federal Emp Program 47 HMO Insurance

Year 12 Opportunities for Prospective Applicants Thanks to the outreach work of universities and colleges, professional bodies and widening participation charities, there now exist a wide range of opportunities for UK maintained-sector students to explore Higher Education in the years before they come to apply. While many providers offer opportunities for KS4 pupils, or even younger year .