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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 2026, 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 out of 5 stars in 2026.
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.
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 $8500.00 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 features a $0 drug deductible, meaning your prescription drug coverage begins immediately. For Tier 1 preferred generic and Tier 2 generic medications, you will pay no copay when using a preferred pharmacy or standard mail order. If you choose a standard pharmacy for these generic tiers, copayments range from $9 to $20 for a one-month supply. For higher-tier medications, costs are based on coinsurance rather than flat copayments across all pharmacy types. You will pay a 25% coinsurance for Tier 3 preferred brand drugs, 42% coinsurance for Tier 4 non-preferred drugs, and 33% coinsurance for Tier 5 specialty drugs. These coinsurance percentages remain consistent whether you fill a one, two, or three-month prescription.
Additional Benefits
Keystone 65 Basic Rx (HMO) offers comprehensive medical coverage with predictable costs, featuring no copay or coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $38 copay, while inpatient hospital stays have a daily copay of $325 for the first seven days and no copay thereafter. Emergency room visits carry a $115 copay, and standard outpatient hospital services require a $355 copay, both with no coinsurance. The plan also includes valuable supplemental benefits, such as routine dental, vision, and hearing exams with no copay, alongside a $250 annual eyewear allowance and up to $2,000 in comprehensive dental coverage with a 10% coinsurance. Additionally, members receive a $60 quarterly over-the-counter item allowance with no copay. Durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Keystone 65 Basic Rx (HMO) inpatient hospital benefits are partially covered with no coinsurance, requiring a daily copay of $325 for days 1-7 of acute stays (no copay for days 8 and beyond) and $295 for days 1-7 of psychiatric stays (no copay for days 8-90). Upgrades, non-Medicare-covered stays, and additional psychiatric days beyond 90 days are not covered.
Outpatient Services See details
Keystone 65 Basic Rx (HMO) covers outpatient hospital services with a $355 copay and observation services with a $325 copay per stay, both with no coinsurance. Ambulatory surgical center services require a $225 copay with no coinsurance, while outpatient substance abuse services have a $20 to $30 copay with no coinsurance, and outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by Keystone 65 Basic Rx (HMO) with a $30.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Keystone 65 Basic Rx (HMO) covers ground and air ambulance services with a $240 copay and no coinsurance, though prior authorization is required and the copay is not waived upon hospital admission. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Keystone 65 Basic Rx (HMO) covers emergency services with a $115 copay and urgently needed services with a $15 to $40 copay, both with no coinsurance. Worldwide emergency and urgent care are partially covered with a $115 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Keystone 65 Basic Rx (HMO) provides primary care physician services with no copay and no coinsurance, and specialist visits for a $38 copay and no coinsurance. Additional services like physical therapy, mental health, and podiatry have copays ranging from $5 to $38 with no coinsurance, while chiropractic benefits are partially covered because other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Keystone 65 Basic Rx (HMO) with no copay and no coinsurance for covered care, though prior authorization is required for Medicare-covered zero-dollar preventive services. While annual physicals, fitness benefits, and health education are included, several supplemental services such as personal emergency response systems, weight management programs, and in-home safety assessments are not covered.
Hearing Services See details
Keystone 65 Basic Rx (HMO) covers Medicare-covered hearing exams for a $38 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays between $699 and $999 for up to two aids per year, though inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Vision services under Keystone 65 Basic Rx (HMO) are partially covered with no deductibles or coinsurance, offering one annual routine eye exam with no copay and other exams with a copay up to $38. Eyewear is covered with no copay up to a $250 annual maximum for one pair of contact lenses or eyeglasses, though individual frames, lenses, upgrades, and other eye exam services are not covered.
Dental Services See details
Dental services under Keystone 65 Basic Rx (HMO) are partially covered, featuring a $38 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for preventive cleanings and exams. Comprehensive benefits like restorative care and implants are covered up to a $2,000 annual maximum with no copay and 10% coinsurance, while orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Keystone 65 Basic Rx (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B chemotherapy, radiation, and other Part B drugs require no copay and a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered by Keystone 65 Basic Rx (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Keystone 65 Basic Rx (HMO) covers medical equipment, including durable medical equipment (DME) and prosthetics, with no copay and a 20% coinsurance. Diabetic supplies and therapeutic shoes are also covered with no copay and coinsurance ranging from no coinsurance to 20%.
Diagnostic and Radiological Services See details
Keystone 65 Basic Rx (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. There is no copay for lab services and diagnostic procedures, while outpatient X-rays require a $40 copay, diagnostic radiology starts with no copay, and therapeutic radiology has a minimum copay of $85.
Home Health Services See details
Home Health Services are covered by Keystone 65 Basic Rx (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Keystone 65 Basic Rx (HMO) provides Cardiac Rehabilitation Services with no coinsurance, though only some services are covered as cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered and require a $5 copay.
Skilled Nursing Facility (SNF) See details
Keystone 65 Basic Rx (HMO) covers skilled nursing facility (SNF) services with no coinsurance and does not require a prior three-day hospital stay, though prior authorization is required. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the standard 100-day limit are not covered.
Other Services See details
Keystone 65 Basic Rx (HMO) partially covers other services, offering acupuncture with a $15.00 copay and no coinsurance for up to 6 treatments per year, and over-the-counter (OTC) items with no copay and no coinsurance up to $60.00 every three months. Meal benefits and other supplemental services are not covered.
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