Summary of Benefits

Covered Benefits and Services

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The Summary of Benefits tells you about some of the plan’s features. You should refer to the Summary of Benefits for:

Benefits
Premiums
Cost-sharing (e.g., copays, coinsurance, and deductibles)
Hospital Tiering

For a copy of the Summary of Benefits:

Download a Summary of Benefits in PDF format:
- Keystone 65 Complete — For people who have full Medicare and Medicaid benefits.
- Keystone 65 Complete — For members with effective date prior to June 1, 2005, who do not have full Medicare and Medicaid benefits.
- Keystone 65 Value/Advantage/Preferred
- Personal Choice 65^SM Standard
- Select Advantage

Submit an online request for a copy to be mailed to your home

Call us:

Call us: 1-877-393-6733 (TTY/TDD 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week

The Summary of Benefits doesn’t list every service we cover or list every limitation or exclusion. To get a detailed list of our benefits, please refer to the Evidence of Coverage.

Extra help is available for those who need it most. Find out whether you qualify for low-income subsidy.