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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 Chester, Delaware, Montgomery 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 $143.00. 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. During the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy. For example, you will pay no copay for preferred generic drugs at preferred and standard mail pharmacies. For standard generic drugs, you will pay 25% coinsurance at any pharmacy. Once 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 range of benefits, including inpatient hospital stays with a $225 copay for the first six days, and no copay for days 7-90. Outpatient services have varying copays, and emergency services have a $140 copay. Preventive services like annual physical exams have no copay, and hearing, vision, and dental services are covered with copays. The plan also includes coverage for ambulance, home health, and skilled nursing facilities, along with other services like acupuncture and OTC items.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $225 copay for days 1-6, and no copay for days 7-90, while additional days 91-999 have no copay, and Non-Medicare-covered Stay and Upgrades are not covered. Inpatient Hospital Psychiatric services also require a $225 copay for days 1-6, and no copay for days 7-90, while Additional Days and Non-Medicare-covered Stay 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, and Group Sessions for Outpatient Substance Abuse with a $20 copay. Outpatient Blood Services have no copay.
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, with a $150 copay for both ground and air ambulance services, and 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 by the Keystone 65 Preferred Rx (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have a copay between $5 and $55; all three have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Keystone 65 Preferred Rx (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, physician specialist services with a $40 copay, mental health specialty services with a $20-$30 copay, podiatry services with a $20 copay, other health care professional services with a $0-$40 copay, psychiatric services with a $20-$30 copay, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a $0-$40 copay, and opioid treatment program services with a $5 copay. Routine chiropractic care is limited to 6 visits per year.
Preventive Services See details
Preventive services include an annual physical exam with no copay, and additional preventive services. Additional preventive services, including health education, Medical Nutrition Therapy, Home-Based Palliative Care, Support for Caregivers of Enrollees, and Fitness Benefit, have 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, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, Counseling Services, Home and Bathroom Safety Devices and Modifications are not covered. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay.
Hearing Services See details
The Keystone 65 Preferred Rx (HMO) plan covers hearing exams with a $40 copay and routine hearing exams with no copay for one visit every year, as well as fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $499 and $799 for two visits every year, but prescription hearing aids - inner ear, outer ear, and over the ear, as well as 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 of $0-$40, and eyewear with a combined maximum benefit of $250 per year. Contact lenses and eyeglasses (lenses and frames) are covered, with one pair allowed per year, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include Medicare Dental Services with a $40 copay, and other services like Oral Exams, Dental X-Rays, and Prophylaxis (Cleaning) with no copay. However, Fluoride Treatment is not covered, and Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are also not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a 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) with a coinsurance between 0% and 20%, Prosthetics and Medical Supplies with a 20% coinsurance, and Diabetic Equipment with a coinsurance between 0% and 20% for Diabetic Supplies and no copay for Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with no copay, Lab Services with no copay, Diagnostic Radiological Services with a maximum copay of $150, Therapeutic Radiological Services with a $60 copay, and Outpatient X-Ray Services with a $40 copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Keystone 65 Preferred Rx (HMO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Keystone 65 Preferred Rx (HMO) plan. Although the plan covers the Cardiac Rehabilitation Services benefit, it does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
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
Under "Other Services," acupuncture is covered with a $20 copay per visit, and up to 6 treatments are covered per year. Over-the-counter (OTC) items are also covered, with a maximum benefit of $30 every three months, but does not include all drugs on the CMS OTC list.
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