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Keystone 65 Focus Rx HMO, our new Medicare Advantage benefit product  

October 1, 2015    

Independence will soon introduce Keystone 65 Focus Rx HMO (Keystone 65 Focus), a new Medicare Advantage HMO benefit product for 2016. Keystone 65 Focus uses a defined-network with more than 23,000 participating providers in southeastern Pennsylvania. Keystone 65 Focus members will enjoy the same benefits as with broader-network Medicare Advantage HMO benefit products while taking advantage of lower premiums and out-of-pocket costs due to their more defined network of providers.

Participating hospitals

The following hospitals are participating in the Keystone 65 Focus network. Please note that if an Independence-participating hospital does not appear on this list, it means the hospital is not participating in the Keystone 65 Focus network. Members who choose Keystone 65 Focus for their health care coverage should only be referred to the hospitals listed below for non-emergency services.

  • Abington Health
    • – Abington Memorial Hospital
    • – Lansdale Hospital
  • Aria Health
  • Community Health Systems
    • – Brandywine Hospital
    • – Chestnut Hill Hospital
    • – Jennersville Regional Hospital
    • – Phoenixville Hospital
    • – Pottstown Memorial Medical Center
  • Doylestown Hospital
  • Grand View Hospital
  • Holy Redeemer Hospital and Medical Center
  • Main Line Hospitals, Inc.
    • – Bryn Mawr Hospital
    • – Lankenau Medical Center
    • – Paoli Hospital
    • – Riddle Hospital
  • St. Luke's Health System
  • Thomas Jefferson University Hospital, Inc.
    • – Methodist Hospital
    • – Thomas Jefferson University Hospital

Keystone 65 Focus benefits

Service category Keystone 65 Focus Rx HMO*
Monthly plan premium Philadelphia and Bucks County Chester, Delaware, and Montgomery County
Medical only N/A N/A
Medical with Choice Program N/A N/A
Medical with Rx $0 $25
Medical with Rx and Choice Program $6 $31
Network Defined network of physicians, ancillary providers, and hospitals
Primary care physician (PCP) visits $10 copay
Specialist visits $40 copay
Emergency care $75 copay (not waived if admitted)
Urgent care $20 in-network urgent care centers ($10 for PCP; $40 for specialist) (not waived if admitted to the hospital)
Worldwide coverage Emergency care and urgently needed care are covered worldwide, $75 copay per visit (not waived if admitted)
Routine chiropractic services $20 copay per visit (up to 6 visits per year)
Routine podiatry services $40 copay per visit (up to 6 visits per year)
Outpatient surgery $150 copay per ambulatory surgical center visit
$250 copay per outpatient hospital facility visit
Inpatient hospital $150 per day for days 1 – 4; $600 maximum per stay; unlimited days per admission
Fitness program SilverSneakers®
Preventive dental and vision care Available only with the Choice Program option: $10 copay for dental exam and cleaning once every 6 months; $10 copay for a routine eye exam and up to $100 allowance for eyewear every 2 years
Hearing services Available only with the Choice Program option: $40 copay for a routine hearing exam. Hearing aid benefit copay of $699 (standard) or $999 (premium) per hearing aid (one per ear per year)
Out-of-pocket maximum for 2016 $5,700
Prescription drugs (optional coverage)
Deductible No deductible for brand prescription drugs
No deductible for generic tier 1 and tier 2 drugs
Copay $2 preferred generic
$15 generic
$47 preferred brand
$100 non-preferred brand
33% coinsurance specialty drug
Initial coverage limit $3,310 in total drug cost
Coverage gap Member pays 58% of generic drug costs and 45% of brand name drug costs until he or she reaches $4,850
Catastrophic Member pays the greater of $2.95 generic and $7.40 brand or 5% coinsurance after reaching $4,850 catastrophic trigger
Mail order (90-day supply) $4 preferred generic
$30 generic
$94 preferred brand
$200 non-preferred brand
33% coinsurance specialty drug

*All Keystone 65 HMO members must use in-network hospitals and physicians with the exception of emergent or urgently needed care. Referrals are required for most services.

For urgently needed care received outside the United States, the emergency room copayment will apply.

Your participation status for the Keystone 65 Focus defined network

We recently mailed providers in our Keystone 65 HMO network eligibility criteria and their participation status for Keystone 65 Focus. If you have any questions about the eligibility criteria or another aspect of the Keystone 65 Focus defined network, please refer to the frequently asked questions on our website. If you still have questions after reviewing this information, please email us.

If you have Medicare patients who are interested in learning more about Keystone 65 Focus, please have them contact Customer Service toll-free at 1-800-645-3965 (TTY/TDD: 711), 8 a.m. to 8 p.m., seven days a week. Please keep in mind that providers must remain neutral when assisting patients with enrollment decisions. Any discussions with patients should be an objective assessment of the patient’s needs and potential options.

SilverSneakers is a registered mark of Healthways, Inc., an independent company.

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