Effective January 1, 2015, there will be several changes to our current Medicare Advantage HMO and PPO plans including the introduction of a new $0 premium plan – Keystone 65 Basic HMO with Rx. Keystone 65 Basic HMO includes a $450 deductible that applies to certain services, including durable medical equipment, inpatient hospital, inpatient mental health, outpatient surgery, and prosthetics. The plan will be available to Medicare beneficiaries in Bucks and Philadelphia counties.

Medicare Advantage HMO and PPO members should have already received their 2015 Annual Notice of Changes/Evidence of Coverage. They will have until December 7, 2014, to make any changes to their health care plans.

The Member Help Team, Independence?s Medicare Customer Service program, will continue to ensure that our Medicare Advantage HMO and PPO members receive special care and attention. This dedicated service team works closely with other areas within Independence — as well as with billing agencies, pharmacies, and physician offices — to respond to member concerns quickly and resolve their issues the first time around. Members can access the Member Help Team by calling the Customer Service number on the back of their ID card.

The following tables highlight some of the Medicare Advantage HMO and PPO benefits changes for 2015. Please note that this is a list of our significant benefits changes, not a comprehensive list of all benefits changes.

Contact your Network Coordinator if you have any questions.

Medicare Advantage HMO and PPO monthly plan premiums

Plan type Keystone 65 Basic HMO Keystone 65 Select HMO Keystone 65 Preferred HMO Personal Choice 65^SM PPO Medical only Not available Philadelphia/Bucks: $0

Chester/Delaware/ Montgomery: $25 Philadelphia/Bucks: $135

Chester/Delaware/ Montgomery: $194 Philadelphia/Bucks: $155 Medical with Choice Program (hearing, dental, vision) Not available Philadelphia/Bucks: $7

Chester/Delaware/ Montgomery: $32 Not available Not available Medical with Rx Philadelphia/Bucks: $0 Philadelphia/Bucks: $25

Chester/Delaware/ Montgomery: $64 Philadelphia/Bucks: $190

Chester/Delaware/ Montgomery: $263 Philadelphia/Bucks: $240 Chester/Delaware/ Montgomery: $113 Medical with Rx and Choice Program Philadelphia/Bucks: $7 Philadelphia/Bucks: $32

Chester/Delaware/ Montgomery: $71 Not available Not available

Medicare Advantage HMO and PPO benefits highlights

Service category Keystone 65 Basic HMO Keystone 65 Select HMO Keystone 65 Preferred HMO Personal Choice 65^SM PPO Primary care physician visits $20 copay per visit $20 copay per visit $10 copay per visit $15 copay per visit Specialist visits $50 copay per visit $45 copay per visit $40 copay per visit $40 copay per visit Emergency room (U.S. 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) $65 copay per visit (not waived if admitted) Urgent care center $30 copay (not waived if admitted to the hospital) $30 copay (not waived if admitted to the hospital) $20 copay (not waived if admitted to the hospital) $20 copay (not waived if admitted to the hospital) Outpatient surgery $150 copay per visit for ambulatory surgical centers, after the deductible is met; $300 copay per visit for outpatient hospital facility, after the deductible is met $150 copay per visit for ambulatory surgical centers; $400 copay per visit for outpatient hospital facility $125 copay per visit for ambulatory surgical centers; $400 copay per visit for outpatient hospital facility $150 copay per visit for ambulatory surgical centers; $400 copay per visit for outpatient hospital facility Inpatient hospital $270 per day for days 1 ? 7 ($1,890 per stay maximum) per admission, after the deductible is met $270 per day for days 1 ? 7 ($1,890 per stay maximum) per admission $240 per day for days 1 ? 7 ($1,680 per stay maximum) $900 per admission; unlimited days per admission Dental, vision, hearing (non-Medicare covered) Benefits available for additional $7 per month in plan premiums through the Choice Program Benefits available for additional $7 per month in plan premiums through the Choice Program Dental: $20 copay for exams and cleanings once every 6 months

Vision: $40 copay once every two years; covered up to $100 every 2 years for eyewear

Hearing: $40 copay once every 3 years; covered up to $500 for hearing aids (two aids) every 3 years Not covered

Using in-network retail clinics

Medicare Advantage HMO and PPO members who go to a network retail clinic for preventive and urgent care will pay the same copayment amount as for a primary care physician office visit. A retail clinic is a type of walk-in clinic located in a supermarket, pharmacy, or retail store where members can receive preventive care or treatment for uncomplicated minor illnesses in a non-emergency setting. Retailers include Walgreens (Healthcare Clinics), CVS (MinuteClinic^®), and Walmart.

Since the types of services vary by location, members are encouraged to call ahead to see if the retail clinic they want to use has the services they need (e.g., some retail clinics do not offer urgent care or flu shots).

Note: Not all retail clinics are a part of our network. To see if a retail clinic is part of the Independence network, members can use the Find a Provider tool. They can also call the Member Help Team for more information using the number on the back of their member ID card.

MinuteClinic, L.L.C. is a Delaware corporation, accredited by The Joint Commission as a retail health provider licenses to operate retail-based health clinics.