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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 2026, 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 out of 5 stars in 2026.
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 $47.00. 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 $6750.00 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 features a $0 drug deductible, meaning your prescription coverage begins immediately with no upfront deductible to meet. You will pay no copay for Tier 1 preferred generic and Tier 2 generic medications when filled through a preferred pharmacy or standard mail order. If you utilize a standard pharmacy, Tier 1 drugs require a copay starting at $9 and Tier 2 drugs require a copay starting at $20. For brand-name and specialty medications, your costs are based on a percentage of the drug's cost. You will pay a 25% coinsurance for Tier 3 preferred brand drugs, a 36% coinsurance for Tier 4 non-preferred drugs, and a 33% coinsurance for Tier 5 specialty drugs. These coinsurance rates remain consistent across preferred pharmacies, standard pharmacies, and standard mail order options.
Additional Benefits
The Keystone 65 Select Rx (HMO) plan offers robust medical coverage with affordable cost-sharing and no coinsurance for many primary services. Beneficiaries enjoy no copay for primary care doctor visits, preventive care, and home health services, while specialist visits require a $40 copay. Inpatient hospital stays require a $295 daily copay for the first seven days, and emergency services are covered with a $130 copay. Routine dental, vision, and hearing exams are fully covered with no copay, while comprehensive dental features a 20% to 40% coinsurance up to a $1,500 annual limit. Durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance. Skilled nursing facility care is also highly accessible, requiring no copay for the first 20 days of your stay.
Inpatient Hospital See details
Keystone 65 Select Rx (HMO) covers inpatient hospital services with prior authorization and no coinsurance, requiring a $295 daily copay for days 1 to 7 and no copay for days 8 to 90 per stay. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional acute care days are covered with no copay.
Outpatient Services See details
Keystone 65 Select Rx (HMO) covers outpatient services with no coinsurance, including a $390 copay for outpatient hospital services, a $295 copay per stay for observation services, and a $250 copay for ambulatory surgical center services. Outpatient substance abuse services require a $30 copay for individual sessions and a $20 copay for group sessions, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Keystone 65 Select Rx (HMO) covers partial hospitalization services with a $30.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Keystone 65 Select Rx (HMO) covers ground and air ambulance services with a $250 copay per service and no coinsurance, subject to prior authorization. Some transportation services are covered, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Keystone 65 Select Rx (HMO) covers emergency services with a $130 copay and urgently needed services with a $15 to $50 copay, both with no coinsurance. Worldwide emergency services are partially covered with a $130 copay and no coinsurance for emergency and urgent care, but worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits under Keystone 65 Select Rx (HMO) feature no copay and no coinsurance for primary care physician visits, while specialist visits have a $40 copay and no coinsurance. Other services like physical therapy and mental health range from a $0 to $40 copay with no coinsurance, though chiropractic care is only partially covered as other non-routine chiropractic services are not covered.
Preventive Services See details
Preventive services under Keystone 65 Select Rx (HMO) are partially covered with no copay and no coinsurance for covered benefits like annual physical exams, fitness benefits, and health education. However, several sub-services are not covered, including personal emergency response systems, weight management programs, alternative therapies, therapeutic massage, and in-home safety assessments.
Hearing Services See details
Keystone 65 Select Rx (HMO) covers hearing exams with no coinsurance, requiring a $40 copay for Medicare-covered exams and no copay for routine annual exams and fittings. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $499 to $799 for up to two aids per year, though inner ear, outer ear, over-the-ear, and OTC hearing aids are not covered.
Vision Services See details
Keystone 65 Select Rx (HMO) offers partially covered vision services with no deductibles, no coinsurance, and no copays for covered services. This benefit includes one routine eye exam and one pair of eyeglasses or contact lenses per year up to a $250 combined maximum, while other eye exams, individual lenses, individual frames, and upgrades are not covered.
Dental Services See details
Keystone 65 Select Rx (HMO) partially covers dental services, including preventive care with no copay and no coinsurance, and Medicare-covered dental with a $40 copay and no coinsurance. Comprehensive services are covered up to a $1,500 annual limit with no copay and 20% to 40% coinsurance, but other diagnostic, other preventive, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Keystone 65 Select Rx (HMO) covers home infusion bundled services with no copay, although prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered by Keystone 65 Select Rx (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Keystone 65 Select Rx (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic therapeutic shoes and inserts are covered with no copay, while diabetic supplies range from no coinsurance to 20% coinsurance, with prior authorization required for most equipment.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Keystone 65 Select Rx (HMO) with no coinsurance, though prior authorization is required. There is no copay for diagnostic tests and lab services, while diagnostic radiological services start at a $0 copay, outpatient X-rays require a $40 copay, and therapeutic radiological services have a minimum copay of $85.
Home Health Services See details
Keystone 65 Select Rx (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Keystone 65 Select Rx (HMO) with no coinsurance. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered and require a $5 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Keystone 65 Select Rx (HMO) with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not required, additional days beyond the standard 100 days are not covered.
Other Services See details
Keystone 65 Select Rx (HMO) provides partial coverage for other services, including acupuncture with a $15 copay and no coinsurance for up to six treatments per year, and over-the-counter items with no copay or coinsurance up to $30 every three months. Meal benefits and other additional services are not covered under this plan.
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