Keystone 65 Preferred Rx (HMO)

Medicare Advantage Plan for Pennsylvania

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderIndependence Blue Cross
Plan IDH3952-45-0
CMS Rating1
Plan TypeHMO
Annual Deductible$0.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$4,000 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$70.80
Monthly Health Plan Premium
$218.20

Benefits

Service
Cost
Inpatient hospital coverage
$250 for days 1 through 6
$0 for days 7 through 90
Outpatient hospital coverage
$400 per visit
Doctor visits
Primary:
$5 per visit
Specialist:
$40 per visit
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$5-40 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$40-150
Outpatient x-rays:
$40
Mental health services
$200 for days 1 through 7
$0 for days 8 through 90
Outpatient group therapy visit with a psychiatrist:
$40
Outpatient individual therapy visit with a psychiatrist:
$40
Outpatient group therapy visit:
$40
Outpatient individual therapy visit:
$40
Skilled Nursing Facility
$0 for days 1 through 20
$150 for days 21 through 100
Rehabilitation services
Occupational therapy visit:
$40
Physical therapy and speech and language therapy visit:
$40
Ambulance
$150
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
$40
Routine foot care:
$40
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
0-20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
$0 copay
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
20%
Other Part B drugs:
20%

Coverage Area for Keystone 65 Preferred Rx (HMO)

StatePennsylvania
CountyPhiladelphia

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$2 copay$7 copayNot offered
Tier 2: Non-Preferred Generic$10 copay$16 copayNot offered
Tier 3: Preferred Brand Name$47 copay$47 copayNot offered
Tier 4: Non-Preferred Brand Name$100 copay$100 copayNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$6 copay$21 copayNot offered
Tier 2: Non-Preferred Generic$30 copay$48 copayNot offered
Tier 3: Preferred Brand Name$141 copay$141 copayNot offered
Tier 4: Non-Preferred Brand Name$300 copay$300 copayNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care management
Not Rated
Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physician Finder

Physicians that accept Keystone 65 Preferred Rx (HMO) for Pennsylvania

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WIKOFF, EDWARD
101 E OLNEY AVE
PHILADELPHIA, PA 19120
SCHINDLER, ALAN
101 E OLNEY AVE
PHILADELPHIA, PA 19120
BELL, GEORGE
101 E OLNEY AVE
PHILADELPHIA, PA 19120
YOO, STANLEY
101 E OLNEY AVE
PHILADELPHIA, PA 19120
BRADY, PAUL
101 E OLNEY AVE
PHILADELPHIA, PA 19120
MATSON, DAVID
101 E OLNEY AVE
PHILADELPHIA, PA 19120
GARCIA, LAUREANO
328 W GODFREY AVE
PHILADELPHIA, PA 19120
WALSH, BRIAN
4702 N 5TH ST
PHILADELPHIA, PA 19120
HOELLEIN, KENNETH
101 E OLNEY AVE
PHILADELPHIA, PA 19120
ITSKOV, BORIS
101 E OLNEY AVE
PHILADELPHIA, PA 19120
GRANT, RICHARD
101 E OLNEY AVE
PHILADELPHIA, PA 19120
LANOCE, GARY
4857 C ST
PHILADELPHIA, PA 19120
SMALL, RONALD
104 W CHELTENHAM AVE
PHILADELPHIA, PA 19120
STEERMAN, PAUL
101 E OLNEY AVE
PHILADELPHIA, PA 19120
NGUYEN, TRUONG
5746 RISING SUN AVE
PHILADELPHIA, PA 19120
BLENDER, BURTON
335 E WYOMING AVE
PHILADELPHIA, PA 19120
TADLEY, GERALD
335 E WYOMING AVE
PHILADELPHIA, PA 19120
BEST, KIMBERLY
101 E OLNEY AVE
PHILADELPHIA, PA 19120
STANILLA, JOSEPH
101 E OLNEY AVE
PHILADELPHIA, PA 19120
HAILS, KEVIN
101 E OLNEY AVE
PHILADELPHIA, PA 19120
COSGROVE, DOUGLAS
101 E OLNEY AVE
PHILADELPHIA, PA 19120
MCCAFFERTY, JOHN
101 E OLNEY AVE
PHILADELPHIA, PA 19120
MYERS, JOHN
101 E OLNEY AVE
PHILADELPHIA, PA 19120
SAMUELS, EYDA
101 E OLNEY AVE
PHILADELPHIA, PA 19120
ROSENSTEIN, KENNETH
101 E OLNEY AVE
PHILADELPHIA, PA 19120
Details
EDWARD WIKOFF, MD
Phone Number
(215) 456-7000
Office Locations
101 E OLNEY AVE
PHILADELPHIA, PA 19120
101 E OLNEY AVE PHILADELPHIA PA, 19120

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