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Keystone 65 Basic Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Basic 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 Basic Rx (HMO) in 2025, please refer to our full plan details page.
Keystone 65 Basic Rx (HMO) is a HMO plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Philadelphia, Bucks, Chester, Delaware, Montgomery. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Keystone 65 Basic 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 Basic 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 Basic Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $6.10. You must continue to pay paying your reduced 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 $7250.00 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 Basic Rx (HMO) plan has no deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For preferred generic drugs, there is no copay at preferred mail pharmacies and a $0 copay at preferred pharmacies. Standard generic drugs have 25% coinsurance, and preferred brand drugs have 50% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Keystone 65 Basic Rx (HMO) plan offers a range of benefits, including inpatient hospital stays with a $250 copay for days 1-7, and no copay for days 8-90, as well as outpatient services with varying copays. You'll also find coverage for primary care with no copay, preventive services like annual exams with no copay, and hearing services including hearing exams with a $30 copay, and routine hearing exams with no copay. Vision services include eye exams with no copay and eyewear with a combined maximum benefit of $250 per year. The plan also includes dental services with a $30 copay for Medicare dental services. Ambulance, emergency, and home health services are covered, along with coverage for home infusion bundled services and medical equipment. Additionally, the plan covers skilled nursing facility stays with no copay for days 1-20 and a $214 copay for days 21-100. Other services like acupuncture and over-the-counter items are also included, with a $15 copay for acupuncture and up to $70 every three months for OTC items.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization. For Inpatient Hospital-Acute, you will pay a $250 copay for days 1-7, and no copay for days 8-90, with additional days covered with no copay. For Inpatient Hospital Psychiatric, you will also pay a $250 copay for days 1-7, and no copay for days 8-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $300 copay, ambulatory surgical center services have a $150 copay, individual outpatient substance abuse sessions have a $30 copay, group outpatient substance abuse sessions have a $20 copay, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Keystone 65 Basic Rx (HMO) plan with a $30 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Keystone 65 Basic Rx (HMO) plan. Ground and Air Ambulance Services have a $240 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 under the Keystone 65 Basic Rx (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, and Urgently Needed Services have a copay between $15 and $45; all services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Keystone 65 Basic Rx (HMO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, physician specialist services with a $30 copay, mental health specialty services with a copay between $20-$30, podiatry services with a $25 copay, other health care professional services with a copay between $0-$30, psychiatric services with a copay between $20-$30, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a copay between $0-$30, and opioid treatment program services with a $5 copay.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, and other services such as health education, medical nutrition therapy, home-based palliative care, support for caregivers of enrollees, and fitness benefits with no copay. The plan also covers kidney disease education, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit with no copay. In-home safety assessments, personal emergency response systems, post-discharge in-home medication reconciliation, readmission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, 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
Hearing services include hearing exams with a $30 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999.
Vision Services See details
Vision services include eye exams with a copay of $0-$30, and eyewear. Eyewear has a combined maximum benefit of $250 every year. The plan covers one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Keystone 65 Basic Rx (HMO) plan covers dental services, including Medicare dental services with a $30 copay, and other dental services. Oral exams, dental X-rays, prophylaxis (cleaning), and fluoride treatments are covered with no copay, but are subject to visit limitations. Restorative services, endodontics, periodontics, prosthodontics, fixed, implant services, and oral and maxillofacial surgery are covered with a 10% coinsurance. 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 with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Keystone 65 Basic Rx (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance with no copay, but Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance with no copay, and Diabetic Supplies have a 0-20% coinsurance with no copay. Diabetic Therapeutic Shoes/Inserts have no copay, and a 0% minimum and maximum coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a $0 copay for Diagnostic Procedures/Tests and Lab Services. Diagnostic Radiological Services have a copay of at most $170, Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have a $40 copay.
Home Health Services See details
Home Health Services are covered by the Keystone 65 Basic 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 Basic Rx (HMO) plan. The plan also does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Keystone 65 Basic 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
Other Services include acupuncture with a $15 copay, and Over-the-Counter (OTC) Items, which are covered up to a maximum of $70 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.
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