Keystone 65 Focus Rx (HMO-POS) | Medicare Advantage Plan Details | Pennsylvania (2024)

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Health Insurance Company: Independence Blue Cross

Medicare Advantage Plan Details

$0 /mo

monthly premium

Keystone 65 Focus Rx (HMO-POS)

Additional Coverage

Overall Star Rating (2024)

  • Rx

  • Dental

  • Vision

  • Hearing

4

out of 5 stars

General Plan Details

Medical Deductible

$0

Out-of-Pocket Maximum

$6500

Rx Drug Coverage

Yes

Rx Deductible

$0

Primary Doctor Office Visit

$0 copay

Specialist Office Visit

$40 copay per visit

Additional Benefits

Doctor & Hospital Coverage

Primary Doctor Office Visit

In-network: $0 copay
Out-of-network: 20% coinsurance per visit

Specialist Office Visit

In-network: $40 copay per visit
Out-of-network: 20% coinsurance per visit

Periodic Exam Coverage

In-network: $0 copay
Out-of-network: 20% coinsurance

Emergency Room

$100 copay per visit (always covered)

Ambulance Coverage

In-network: $230 copay
Out-of-network: 20% coinsurance

Lab, X-Ray, Radiology Coverage

Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0 copay
Out-of-network: 20% coinsurance
Medicare-covered lab services: In-network: $0 copay
Out-of-network: 20% coinsurance
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0-160 copay
Out-of-network: 20% coinsurance
Medicare-covered x-ray services: In-network: $30 copay
Out-of-network: 20% coinsurance

Outpatient Surgery Coverage

Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $325 copay per visit
Out-of-network: 20% coinsurance per visit

Hospitalization Coverage

Inpatient hospital-acute:
In-network: $210 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 90 and beyond
Out-of-network: 20% per stay
Inpatient hospital psychiatric:
In-network: $210 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-network: 20% per stay

Rehabilitation Coverage

Occupational therapy services:
In-network: $20 copay
Out-of-network: 20% coinsurance
Physical therapy and speech and language therapy services:
In-network: $20 copay
Out-of-network: 20% coinsurance

Urgent Care Coverage

$10-40 copay per visit (always covered)

Skilled Nursing Facility (SNF)

In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 100
Out-of-network: 20% per stay

Mental Health Coverage

Medicare-covered individual sessions: In-network: $30 copay
Out-of-network: 20% coinsurance
Medicare-covered group sessions: In-network: $20 copay
Out-of-network: 20% coinsurance

Dental, Vision, Hearing Benefits

Dental Services

Oral exams: In-network: $0 copay
Out-of-network: No Data
Prophylaxis (cleaning): In-network: $0 copay
Out-of-network: No Data
Dental x-rays: In-network: $0 copay
Out-of-network: No Data

Vision Benefits

Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: No Data
Eyewear:
Contact Lenses: In-network: $0 copay
Out-of-network: No Data
Eyeglasses: In-network: $0 copay
Out-of-network: No Data

Hearing Benefits

Hearing exams:
Routine hearing exams: In-network: $40 copay
Out-of-network: 20% coinsurance
Hearing aids:
Hearing aids (all types): In-network: $699-999 copay
Out-of-network: No Data

Rx Drug Coverage - Preferred Retail Cost

Tier 1: Preferred Generic

$0.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 2: Generic

$8.00 copay (30-day supply)
$16.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

33% coinsurance (30-day supply)
33% coinsurance (90-day supply)

Rx Drug Coverage - Standard Retail Cost

Tier 1: Preferred Generic

$9.00 copay (30-day supply)
$27.00 copay (90-day supply)

Tier 2: Generic

$20.00 copay (30-day supply)
$60.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

33% coinsurance (30-day supply)
33% coinsurance (90-day supply)

Rx Drug Coverage - Standard Mail Order Cost

Tier 1: Preferred Generic

$0.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 2: Generic

$8.00 copay (30-day supply)
$16.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$94.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$200.00 copay (90-day supply)

Tier 5: Specialty Tier

33% coinsurance (30-day supply)
33% coinsurance (90-day supply)

More Additional Benefits

Annual physical exams

Yes

Chiropractic Coverage

Yes

Acupuncture

Yes

Massage Therapy

No

Health Education

Yes

Counseling Services

No

Support for Caregivers of Enrollees

No

Personal Emergency Response System (PERS)

No

In-home support services

No

Home and bathroom safety devices

No

Meals for short duration

No

Plan Links

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(888) 311-4264

TTY 711

Mon-Fri: 8am-9pm, Sat: 9am-8pm ET

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Where This Plan is Available

State:

Pennsylvania

Counties:

Bucks, Philadelphia

View all plans in your Pennsylvania County

Additional Plan Info

Plan Year:

2024

Insurance Company Website:

Independence Blue Cross

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Enrollment in a plan may be limited to certain times of the year unless you qualify for a special enrollment period or you are in your Medicare Initial Election Period. Not all plans offer all benefits mentioned. Benefits may vary by carrier and location. Limitations and exclusions may apply.

Part B Giveback Disclaimer: the standard Part B premium for 2024 is $174.70. Monthly savings varies and may be subject to processing delays and may not be immediate. Not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower.

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Keystone 65 Focus Rx (HMO-POS) | Medicare Advantage Plan Details | Pennsylvania (2024)

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