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Keystone 65 Select Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Select 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 Select Rx (HMO) in 2025, please refer to our full plan details page.
Keystone 65 Select 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 Select 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 Select 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 Select Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $42.00. 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 $6000.00 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 Select Rx (HMO) plan has an enhanced alternative drug benefit. The plan has no deductible for prescription drugs. In the initial coverage phase, you may pay a $0 copay for preferred generic drugs at preferred pharmacies and mail order, $20 copay at standard pharmacies. For standard generic drugs, you pay 25% coinsurance. For preferred brand drugs, you pay 50% coinsurance, and for non-preferred drugs, you pay 33% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Keystone 65 Select Rx (HMO) plan offers a wide range of benefits with varying cost structures. Inpatient hospital stays have a $275 copay for the first six days, with no copay for the remainder, while outpatient services have a $350 copay. Primary care visits are covered with no copay, and preventive services, including annual physical exams, also have no copay. Additional benefits include coverage for ambulance services with a $225 copay, along with hearing and vision services that have copays or coinsurance. Dental services are covered with no copay for oral exams and cleanings, but restorative services have a 20-40% coinsurance. The plan also covers home health services and skilled nursing facilities, with no copay for the first 20 days of a SNF stay.
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 $275 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, you will also pay a $275 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient services, including all outpatient hospital services, are covered by the Keystone 65 Select Rx (HMO) plan. Outpatient hospital services and observation services have a $350 copay, while ambulatory surgical center services have a $200 copay. Individual and group outpatient substance abuse sessions have a $30 and $20 copay, respectively. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Keystone 65 Select 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. Ground and Air Ambulance Services have a $225 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 Select Rx (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a copay between $15 and $55; there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Keystone 65 Select 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, and mental health specialty services with a copay ranging from $20 to $30. This plan also covers podiatry services with a $20 copay, other health care professional services with a copay from $0 to $40, psychiatric services with a copay from $20 to $30, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a copay from $0 to $40, and opioid treatment program services with a $5 copay.
Preventive Services See details
Preventive services include annual physical exams with no copay, as well as additional preventive services such as Health Education, Fitness Benefit, Home-Based Palliative Care, Support for Caregivers of Enrollees, Kidney Disease Education Services, and Other Preventive Services, all of which have no copay. However, In-Home Safety Assessment, Personal Emergency Response System (PERS), 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
The Keystone 65 Select Rx (HMO) plan covers hearing exams with a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, with a copay between $499 and $799 for all types of prescription hearing aids, but not for inner ear, outer ear, or over the ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
Keystone 65 Select Rx (HMO) covers vision services, including eye exams with a copay between $0 and $40. Eyewear is covered, with a combined maximum benefit of $250 every year, and contact lenses and eyeglasses (lenses and frames) are covered. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Keystone 65 Select Rx (HMO) plan covers dental services including oral exams with no copay, and dental x-rays, prophylaxis (cleaning), and fluoride treatment with no copay. Restorative services, endodontics, periodontics, prosthodontics, fixed, and implant services have a 20-40% coinsurance, while prosthodontics, removable has a 40% coinsurance. Orthodontic services are covered with a $2,000 maximum benefit per year. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay, and 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 by the Keystone 65 Select Rx (HMO) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with a 20% coinsurance and requires authorization, along with Prosthetic Devices, Medical Supplies, and Diabetic Equipment. Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $200, Therapeutic Radiological Services have a minimum copay of $80, and Outpatient X-Ray Services have a $40 copay.
Home Health Services See details
Home Health Services are covered by the Keystone 65 Select Rx (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Keystone 65 Select Rx (HMO) plan. This includes 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Keystone 65 Select Rx (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Keystone 65 Select Rx (HMO) plan covers acupuncture with a $20 copay, and also covers Over-the-Counter (OTC) items, with a maximum benefit coverage amount of $30 every three months. The plan does not cover meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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