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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 Chester, Delaware, Montgomery 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 $74.00. 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, allowing your prescription coverage to begin immediately. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay when using a preferred pharmacy or standard mail order. If you utilize a standard pharmacy, Tier 1 drugs require a copay starting at $9 for a one-month supply, while Tier 2 drugs require a $20 copay. For higher-tier medications, costs are calculated as a percentage of the drug cost rather than a flat copay. Tier 3 preferred brand drugs require a 25% coinsurance, Tier 4 non-preferred drugs require a 36% coinsurance, and Tier 5 specialty medications carry a 33% coinsurance. These coinsurance rates remain the same whether you fill your prescriptions at a preferred pharmacy, standard pharmacy, or through standard mail order.
Additional Benefits
The Keystone 65 Select Rx (HMO) plan offers robust healthcare coverage with predictable out-of-pocket costs, including no copay for primary care physician visits, routine preventive services, and home health care. Specialist office visits require a $40 copay, while inpatient hospital stays carry a $295 daily copay for the first seven days. Emergency room care is covered with a $130 copay, and urgent care visits range from a $15 to $50 copay. Essential ancillary benefits are also covered, featuring no copay for routine dental, vision, and hearing exams, alongside a $250 annual eyewear allowance and affordable prescription hearing aid copays. Diagnostic lab tests and select over-the-counter items up to $30 quarterly also feature no copay, while durable medical equipment and dialysis require a standard 20% coinsurance.
Inpatient Hospital See details
Keystone 65 Select Rx (HMO) covers inpatient hospital acute and psychiatric care with no coinsurance, requiring a $295 daily copay for days 1 through 7 and no copay for days 8 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, although 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 outpatient hospital services for a $390 copay, observation services for a $295 copay per stay, and ambulatory surgical center services for a $250 copay. Outpatient substance abuse services require a $20 copay for group sessions or a $30 copay for individual sessions with no coinsurance, while outpatient blood services are covered with no copay and no 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 access this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Keystone 65 Select Rx (HMO), with Medicare-covered ground and air ambulance services requiring a $250 copay and no coinsurance. Prior authorization is required for ambulance services, and while some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
Keystone 65 Select Rx (HMO) covers emergency services with a $130 copay and no coinsurance, and urgently needed services with a $15 to $50 copay and no coinsurance. Worldwide emergency and urgent care are partially covered with a $130 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Keystone 65 Select Rx (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Other medical services like physical therapy, mental health, and podiatry are covered with copays ranging from $0 to $40 and no coinsurance, though other chiropractic services are not covered.
Preventive Services See details
Keystone 65 Select Rx (HMO) offers partially covered preventive services with no copay and no coinsurance for covered benefits like annual physical exams and fitness programs. However, sub-services such as in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, in-home support, smoking cessation, telemonitoring, home safety modifications, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by Keystone 65 Select Rx (HMO), featuring a $40 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for routine exams and fitting evaluations. Prescription hearing aids are covered with no coinsurance and a $499 to $799 copay for up to two aids per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Keystone 65 Select Rx (HMO) with no deductibles, offering one routine eye exam and up to $250 annually for eyewear with no copay and no coinsurance. While contact lenses and complete eyeglasses are covered, other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Keystone 65 Select Rx (HMO), offering Medicare-covered dental for a $40 copay and no coinsurance, and preventive care with no copay and no coinsurance. Comprehensive services require no copay and 20% to 40% coinsurance up to a $1,500 yearly maximum, but other diagnostic services, other preventive services, 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, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Keystone 65 Select Rx (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Keystone 65 Select Rx (HMO) covers durable medical equipment and prosthetics with no copay and 20% coinsurance, subject to prior authorization. Covered diabetic equipment and supplies feature no copay for therapeutic shoes or inserts and range from no coinsurance to 20% coinsurance, limited to specified manufacturers.
Diagnostic and Radiological Services See details
Keystone 65 Select Rx (HMO) covers diagnostic and radiological services with no coinsurance, although prior authorization is required. There is no copay for diagnostic procedures, lab services, and diagnostic radiological services, while 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, though prior authorization is required.
Cardiac Rehabilitation Services See details
Keystone 65 Select Rx (HMO) covers some Cardiac Rehabilitation Services with no coinsurance, though standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $5 copay.
Skilled Nursing Facility (SNF) See details
Keystone 65 Select Rx (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and prior authorization required, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. A prior three-day inpatient hospital stay is not required for admission, though additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Other services are partially covered by Keystone 65 Select Rx (HMO), which offers acupuncture with a $15 copay and no coinsurance for up to 6 treatments yearly, and over-the-counter items with no copay and no coinsurance up to $30 every three months. Meal benefits are not covered under this plan.
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