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As a reminder, effective January 1, 2014, there are
several changes to our current Medicare Advantage
HMO and PPO plans including the following highlights:
- Keystone 65 Select HMO with Rx is now available with
a $0 premium in Philadelphia and Bucks counties.
- Keystone 65 Select HMO plan features a $0 premium
for medical-only plans in Philadelphia, Bucks, Chester,
Delaware, and Montgomery counties.
- Our Personal Choice 65SM PPO coverage area has
expanded to Chester, Delaware, and Montgomery
counties, where members can choose a medical plan
with prescription drug coverage for a $98.50 monthly
premium.
We are also pleased to introduce the Member Help
Team, IBC's new Medicare Customer Service program.
Recognizing that Medicare-eligible members have
unique needs, the Member Help Team ensures they
receive special care and attention. This dedicated
service team is designed to work closely with other
areas within IBC ? as well as with billing agencies,
pharmacies, and doctor's offices ? to respond to
members' concerns quickly and resolve their issues
the first time around. Members will experience this new
service when they call the Customer Service number on
the back of their ID cards.
The following tables highlight some of the Medicare
Advantage HMO and PPO benefits changes for 2014.
Please note that this is a list of our significant benefits
changes, not a comprehensive list of all benefits
changes.
Please contact Customer Service if you have any
questions.
Plan type
Keystone 65 Select HMO
Keystone 65 Preferred HMO
Personal Choice 65SM
PPO
Medical only
Philadelphia/Bucks: $0
Chester/Delaware/
Montgomery: $0
Philadelphia/Bucks: $125.40
Chester/Delaware/
Montgomery: $184.80
Philadelphia/Bucks: $145
Medical with Choice Program
(hearing/dental/vision)
Philadelphia/Bucks: $7
Chester/Delaware/
Montgomery: $7
Not available
Not available
Medical with Rx
Philadelphia/Bucks: $0
Chester/Delaware/
Montgomery: $43
Philadelphia/Bucks: $182.60
Chester/Delaware/
Montgomery: $252
Philadelphia/Bucks: $222.50
Chester/Delaware/
Montgomery: $98.50
Medical with Rx and
Choice Program
Philadelphia/Bucks: $7
Chester/Delaware/
Montgomery: $50
Not available
Not available
Service category
Keystone 65 Select HMO
Keystone 65 Preferred HMO
Personal Choice 65SM PPO
Primary care physician
visits
$15 copay per visit for
medical only
$18 copay per visit for
medical with Rx
$5 copay per visit
$10 copay per visit
Specialist visits
$45 copay per visit
$40 copay per visit
$40 copay per visit
Emergency room (United
States and worldwide)
$65 copay per visit
(not waived if admitted)
$65 copay per visit
(not waived if admitted)
$65 copay per visit
(not waived if admitted)
Urgent care
$15 ? $45 copay; not waived
if admitted to the hospital
$18 ? $45 copay for medical
with Rx; not waived if
admitted to the hospital
(Urgent care center:
$25 copay)
$5 ? $40 copay; not waived
if admitted to the hospital
(Urgent care center:
$20 copay)
$10 ? $40 copay; not waived
if admitted to the hospital
(Urgent care center:
$20 copay)
Outpatient surgery
$75 copay per visit for
ambulatory surgical centers;
$0 ? $400 copay per visit for
outpatient hospital facility
$75 copay per visit for
ambulatory surgical centers;
$0 ? $400 copay per visit for
outpatient hospital facility
$75 copay per visit for
ambulatory surgical centers;
$0 ? $400 copay per visit for
outpatient hospital facility
Inpatient hospital
$245 per day for days 1 ? 7
($1,715 per stay maximum);
Unlimited days each benefit period
$215 per day for days 1 ? 7
($1,505 per stay maximum);
Unlimited days each
benefit period
$850 per admission;
unlimited days per admission
Dental, vision, hearing
Benefits available for
additional $7 per month
in plan premiums
Dental: $15 copay for exams
and cleanings once every
6 months
Vision: $40 copay; up to
$100 for eyewear every
2 years
Hearing: $40 copay; up to
$500 for hearing aids (2 aids)
every 3 years
Not covered
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