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How the Plans Work

Keystone 65

Prescription Drug Benefit Resources

With Keystone 65 HMO — a Medicare Advantage HMO — you choose a primary care physician (PCP) from the Keystone 65 HMO network. Your PCP arranges referrals to the other doctors, hospitals, and health care services you need within the network. There is no need to submit claim forms for most services: simply show your Keystone 65 HMO ID card.

The Keystone 65 HMO network includes more than 3,000 primary care physicians and more than 40,000 specialist sites, as well as more than 100 hospitals in our service area.

Monthly premiums

The chart below provides a comparison of the different plan options offered by Keystone 65 HMO and what you will pay each month:

Keystone 65 Advantage HMO
Keystone 65 Preferred HMO
Medical-Only Plan

$52.00 (Philadelphia/Bucks)
$105.00 (Chester/Delaware/Montgomery)

$87.00 (Philadelphia/Bucks)
$152.00 (Chester/Delaware/Montgomery)
Medical plus prescription drug

$82.30 (Philadelphia/Bucks)
$135.30 (Chester/Delaware/Montgomery)

$128.20 (Philadelphia/Bucks)
$193.30 (Chester/Delaware/Montgomery)

Prescription drug coverage

You may select a plan with or without prescription coverage. If you choose to enroll in a plan with Part D, you’ll have the convenience of paying just one premium each month for both your medical and drug coverage. Check the Drug Formulary for a complete listing of covered drugs.

The Keystone 65 HMO Advantage Rx and Preferred Rx plans include Medicare Part D prescription drug coverage. You can go to thousands of pharmacies within the network and simply present your Keystone 65 HMO card. However, covered Part D drugs are available at out-of-network pharmacies in special circumstances while traveling within the United States. You will need to pay the entire cost of the drug, and we will reimburse you the full amount minus the applicable cost-sharing.

How the Rx Option works:

The chart below provides a comparison of how the Part D coverage works for all three Keystone 65 HMO options:

Keystone 65 Advantage Rx HMO
Keystone 65 Preferred Rx HMO
Deductible $280 yearly deductible $100 yearly deductible
Copay

After you pay the yearly deductible you will pay:

  • $3 for generics
  • $30 for preferred brand
  • $65 for non-preferred brand
  • 25% Specialty

You will pay:

  • $5 for generics
  • $30 for preferred brand
  • $80 for non-preferred brand
  • 25% Specialty
Gap coverage

After the total cost of drugs paid by you, the plan, and/or others making payments on your behalf reach $2,830, the member will pay 100 percent of the cost of other drugs through the coverage gap until the member’s total out-of-pocket drug costs reach $4,550.

After the total cost of drugs paid by you, the plan, and/or others making payments on your behalf reach $2,830, the member will pay a $5 copay for the cost of generic drugs and 100 percent of the cost of other drugs through the coverage gap until the member’s total out-of-pocket drug costs reach $4,550.
Maximum out-of-pocket costs

After you reach $4,550, you pay the greater of either:

  • $2.50 for generic drugs or $6.30 for all other drugs or
  • 5% of your drug costs.

After you reach $4,550, you pay the greater of either:

  • $2.50 for generic drugs or $6.30 for all other drugs or
  • 5% of your drug costs.

Summary of Benefits

For details of covered services, copays, and deductibles for the Keystone 65 HMO plans, see the Summary of Benefits.

Need extra help with health plan and drug costs?

If you have limited income and resources, you may qualify for low-income subsidy. When you join Keystone 65, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. If you qualify, your drug costs will also be lower.

You can see if you qualify for a low-income subsidy by calling:

  • 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day/7 days a week

  • Pennsylvania Office of Medical Assistance Programs (Medicaid) at 1-717-787-1870

  • The Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778), 7 a.m. to 7 p.m., Monday through Friday

Benefits, formulary, pharmacy and provider networks, premiums, and/or copays may change on January 1, 2010. Please contact Keystone 65 HMO for details.

Important Note:

If you’re interested in this drug benefit, you must choose Keystone 65 HMO Advantage Rx or Preferred Rx, or another plan that includes prescription coverage. You cannot get a stand-alone prescription drug plan if you opt for a Keystone 65 HMO Medical-Only plan. If you’re interested in a Medicare supplement with a stand-alone prescription drug option, see Security 65®.

To obtain more information, please call 1-877-393-6733 (TTY/TDD: 1-877-219-5457), 8 a.m. to 8 p.m., seven days a week.