A non-government entity
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 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 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 $69.00. 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:
Sign up for Keystone 65 Select Rx (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Keystone 65 Select Rx (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy type. For example, preferred generic drugs have no copay at preferred pharmacies and standard mail, but have a $20 copay at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Keystone 65 Select Rx (HMO) plan offers a range of benefits with varying cost-sharing. You'll find no copays for primary care visits, many preventive services, and home health services. The plan also covers services such as outpatient care, emergency services, and hearing and vision services, with associated copays or coinsurance. The plan includes coverage for inpatient and outpatient hospital care, with copays applying to some services. The plan also covers ambulance services, dental, and medical equipment, as well as home infusion, dialysis, and skilled nursing facility services. However, some services, such as cardiac rehabilitation, are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $275 copay for days 1-6, and no copay for days 7-90, and for Inpatient Hospital Psychiatric, you will pay a $275 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital Psychiatric, Non-Medicare-covered Stay for Inpatient Hospital Psychiatric, and Upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
The Keystone 65 Select Rx (HMO) plan covers outpatient services, including outpatient hospital services with a $350 copay, observation services with a $350 copay, ambulatory surgical center (ASC) services with a $200 copay, and outpatient substance abuse services with a $30 copay for individual sessions and a $20 copay for group sessions. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Keystone 65 Select Rx (HMO) plan, but requires prior authorization. You will have a $30 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Keystone 65 Select Rx (HMO) plan. Ground and Air Ambulance Services have a $225 copay, with no coinsurance, while 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 Select Rx (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay and no coinsurance, while Urgently Needed Services have a copay between $15 and $55, and no coinsurance. 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 and routine chiropractic care have a $20 copay, with routine care limited to 6 visits per year. Occupational Therapy Services have a $20 copay. Physician specialist services have a $40 copay, while mental health and psychiatric individual sessions have a $30 copay, and group sessions have a $20 copay. Physical therapy and speech-language pathology services have a $20 copay. Additional telehealth benefits range from no copay to a $40 copay, and Opioid Treatment Program Services have a $5 copay.
Preventive Services See details
The Keystone 65 Select Rx (HMO) plan covers preventive services, including an annual physical exam with no copay. Other preventive services are covered, and the plan also covers Health Education, Medical Nutrition Therapy, Home-Based Palliative Care, Support for Caregivers of Enrollees, and Fitness Benefits, all with no copay. The plan does not cover 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, In-Home Support Services, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, or Counseling Services.
Hearing Services See details
Keystone 65 Select Rx (HMO) 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 depending on the type of aid, but the plan does not cover inner ear, outer ear, or over-the-ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
Vision Services includes eye exams with a copay of $0-$40, and eyewear with a combined maximum of $250 every year. Contact lenses and eyeglasses (lenses and frames) are covered, with one pair covered every year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services coverage includes a $40 copay for Medicare Dental Services. Oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments have no copay. Restorative services, endodontics, periodontics, implant services, and prosthodontics (removable and fixed) have 20% to 40% coinsurance, and oral and maxillofacial surgery has 20% to 40% coinsurance. Maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B drugs, are covered under the Keystone 65 Select Rx (HMO) plan. Specifically, the plan has a $35 copay for Medicare Part B Insulin Drugs, 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 with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance. Diabetic Equipment is also covered, with a coinsurance and copay, and Diabetic Supplies have between 0% and 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have no copay, Lab Services have no copay, Diagnostic Radiological Services have a copay of at most $200, Therapeutic Radiological Services have a copay of at most $80, and Outpatient X-Ray Services have a $40 copay.
Home Health Services See details
Home Health Services are covered under 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 by the Keystone 65 Select Rx (HMO) plan. While the plan covers some Cardiac Rehabilitation Services, it does not cover any of the sub-services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Keystone 65 Select Rx (HMO) plan, with a prior authorization requirement. For days 1-20, there is no copay, while days 21-100 have a $214 copay.
Other Services See details
Other Services include acupuncture and over-the-counter (OTC) items. Acupuncture has a $20 copay, while OTC items are covered up to $30 every three months. Other services such as meal benefit, dual eligible SNPs with highly integrated services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and others are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved