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Keystone 65 Preferred Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Preferred Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Keystone 65 Preferred Rx (HMO) in 2025, please refer to our full plan details page.
Keystone 65 Preferred Rx (HMO) is a HMO plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Bucks, Philadelphia Counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Keystone 65 Preferred Rx (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Keystone 65 Preferred Rx (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Keystone 65 Preferred Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $173.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Keystone 65 Preferred Rx (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay different amounts depending on the drug tier and pharmacy. For preferred generic drugs, there is no copay at preferred and mail order pharmacies, and a $20 copay at standard pharmacies. Standard generic drugs, preferred brand drugs, and non-preferred drugs have a coinsurance, which is a percentage of the drug's cost. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Keystone 65 Preferred Rx (HMO) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services, primary care, and preventive services often have copays, with some services offered at no cost. The plan also includes coverage for hearing, vision, and dental services with associated copays, as well as ambulance, emergency, and home health services. Additional benefits include coverage for home infusion, dialysis, medical equipment, and diagnostic services with copays or coinsurance. The plan also includes coverage for cardiac rehabilitation and skilled nursing facilities, and offers acupuncture and over-the-counter items with specific limitations.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for both acute and psychiatric care. For Inpatient Hospital-Acute, you pay a $225 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute have no copay. Inpatient Hospital Psychiatric has a $225 copay for days 1-6, and no copay for days 7-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $350 copay, Observation Services with a $350 copay, Ambulatory Surgical Center (ASC) Services with a $125 copay, Individual Sessions for Outpatient Substance Abuse with a $30 copay, Group Sessions for Outpatient Substance Abuse with a $20 copay, and Outpatient Blood Services with no copay. Prior authorization is required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Keystone 65 Preferred Rx (HMO) plan, with a $30 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Keystone 65 Preferred Rx (HMO) plan. Both Ground and Air Ambulance Services have a $150 copay, with no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Keystone 65 Preferred Rx (HMO) plan. Emergency Services has a $140 copay, Urgently Needed Services has a $5-$55 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $140 copay. Worldwide Emergency Transportation is not covered. There is no coinsurance for any of these services.
Primary Care See details
The Keystone 65 Preferred Rx (HMO) plan covers primary care physician services with no copay. Chiropractic services have a $20 copay, and routine chiropractic care has a $20 copay for up to 6 visits per year. Occupational therapy services have a $20 copay, while physician specialist services have a $40 copay. Mental health specialty services have a $30 copay for individual sessions and a $20 copay for group sessions. Podiatry services and routine foot care have a $20 copay for up to 6 visits per year. Other health care professional visits have copays between $0 and $40. Psychiatric services have a $30 copay for individual sessions and a $20 copay for group sessions. Physical therapy and speech-language pathology services have a $20 copay, and additional telehealth benefits have copays between $0 and $40. Opioid treatment program services have a $5 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with prior authorization, annual physical exams with no copay, and additional preventive services. The plan covers additional preventive services, including health education, medical nutrition therapy, home-based palliative care, support for caregivers, and fitness benefits, all with no copay. Other services like In-Home Safety Assessment, Personal Emergency Response System, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, In-Home Support Services, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. The plan also covers Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay.
Hearing Services See details
Hearing services include hearing exams with a $40 copay, routine hearing exams with no copay for 1 visit per year, and fitting/evaluation for a hearing aid with no copay. Prescription hearing aids are partially covered, with a copay between $499 and $799 for all types, but not for inner ear, outer ear, or over-the-ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
The Keystone 65 Preferred Rx (HMO) plan covers vision services, including eye exams with a copay between $0 and $40. Eyewear is covered up to a combined maximum of $250 per year, and contact lenses and eyeglasses (lenses and frames) are each covered once per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services with the Keystone 65 Preferred Rx (HMO) plan include Medicare dental services with a $40 copay. Oral exams, dental x-rays, and prophylaxis (cleaning) are covered with no copay, but fluoride treatments, orthodontic services, and other services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Keystone 65 Preferred Rx (HMO) plan. There is a 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has no copay and a coinsurance between 0% and 20%, while DME for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have a coinsurance between 0% and 20%, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
The Keystone 65 Preferred Rx (HMO) plan covers diagnostic and radiological services. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $150, Therapeutic Radiological Services have a minimum copay of $60, and Outpatient X-Ray Services have a copay of $40.
Home Health Services See details
Home Health Services are covered by the Keystone 65 Preferred Rx (HMO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. There is a copay for the Cardiac Rehabilitation Services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Keystone 65 Preferred Rx (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Keystone 65 Preferred Rx (HMO) plan covers acupuncture with a $20 copay for up to 6 treatments per year, and also covers over-the-counter (OTC) items up to $30 every three months. Other services such as meal benefits, Early and Periodic Screening, and Home and Community Based Services are not covered.
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