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Keystone 65 Essential Rx (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Keystone 65 Essential Rx (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Keystone 65 Essential Rx (HMO-POS) in 2025, please refer to our full plan details page.
Keystone 65 Essential Rx (HMO-POS) is a HMO-POS plan offered by Independence Health Group, Inc. available for enrollment in 2025 to people living in Philadelphia, Bucks, Chester, Montgomery, Delaware. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Keystone 65 Essential Rx (HMO-POS) 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 Essential Rx (HMO-POS).
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 Essential Rx (HMO-POS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $2.10. 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 $7650.00 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 Essential Rx (HMO-POS) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay different amounts depending on the drug tier and pharmacy type. For example, preferred generic drugs have no copay at preferred pharmacies and mail order, but have a $20 copay at standard pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, you may pay a reduced premium.
Additional Benefits
The Keystone 65 Essential Rx (HMO-POS) plan offers a range of health benefits with varying costs. Inpatient hospital stays have a $525 copay per admission, while outpatient services like doctor visits may have copays ranging from $0 to $30. The plan also covers preventive services, including annual physical exams with no copay, and offers additional benefits such as dental, vision, and hearing services with specific copays and coverage limits. This plan includes coverage for emergency services with a $110 copay, along with ambulance services with a $220 copay. It also provides transportation services to plan-approved health-related locations for 12 one-way trips per year. Additionally, the plan covers home health services and skilled nursing facility stays, with specific copay structures.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both with a $525 copay per admission or stay. Additional Days for Inpatient Hospital-Acute have no copay, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
The Keystone 65 Essential Rx (HMO-POS) plan covers outpatient services including outpatient hospital services with a $275 copay, observation services with a $275 copay, ambulatory surgical center services with a $225 copay, individual outpatient substance abuse sessions with a $30 copay and group sessions with a $20 copay, and outpatient blood services with no copay. Prior authorization is required for outpatient hospital services and ambulatory surgical center services.
Partial Hospitalization See details
Partial Hospitalization is covered with a $30 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services with a $220 copay. Transportation Services to a plan-approved health-related location are covered for 12 one-way trips per year, with no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered under the Keystone 65 Essential Rx (HMO-POS) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a copay between $5 and $45; Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services have no copay. Chiropractic Services have a $15 copay for routine care, up to 6 visits per year. Occupational Therapy Services have a $25 copay. Physician Specialist Services have a $25 copay. For Mental Health Specialty Services, individual sessions have a $30 copay and group sessions have a $20 copay. Podiatry Services, including routine foot care, have a $25 copay for up to 6 visits per year. Other Health Care Professional services have a copay between $0 and $25. Individual Psychiatric sessions have a $30 copay, and group sessions have a $20 copay. Physical Therapy and Speech-Language Pathology Services have a $25 copay. Additional Telehealth Benefits have a copay between $0 and $25. Opioid Treatment Program Services have a $5 copay.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay. The plan also covers additional preventive services, kidney disease education services, and other preventive services with no copay for specific services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. Some services, such as 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, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $25 copay, and routine hearing exams are covered with no copay for one visit per year, while fitting/evaluation for hearing aids has no copay. Prescription hearing aids are covered with a copay between $399 and $699 for up to two visits per year for all types of hearing aids, but not for inner, outer, or over-the-ear hearing aids, and OTC hearing aids are not covered.
Vision Services See details
The Keystone 65 Essential Rx (HMO-POS) plan covers vision services, including eye exams with a copay of $0-$25. Eyewear is covered with a combined maximum benefit of $250 per year, and contact lenses and eyeglasses (lenses and frames) are covered, limited to one pair per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Keystone 65 Essential Rx (HMO-POS) plan covers dental services, including oral exams with no copay and dental x-rays, prophylaxis (cleaning), and fluoride treatment with no copay. Orthodontic services are also covered, with a maximum benefit of $3,000 per year. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Implant Services, and Oral and Maxillofacial Surgery are covered with no coinsurance. However, 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, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Keystone 65 Essential Rx (HMO-POS) plan. You will pay 20% coinsurance for this service.
Medical Equipment See details
Medical Equipment is covered by the Keystone 65 Essential Rx (HMO-POS) plan, with Durable Medical Equipment subject to 20% coinsurance and requiring authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have a coinsurance between 0% and 20% and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with no copay, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $260, Therapeutic Radiological Services with a copay of $80, and Outpatient X-Ray Services with a $30 copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Keystone 65 Essential Rx (HMO-POS) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Keystone 65 Essential Rx (HMO-POS) plan. While the plan generally covers Cardiac Rehabilitation Services, the plan does not cover the sub-services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Keystone 65 Essential Rx (HMO-POS) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The "Other Services" benefit in the Keystone 65 Essential Rx (HMO-POS) plan covers acupuncture with a $15 copay for up to 6 treatments per year, as well as over-the-counter (OTC) items with a maximum benefit of $100 every three months. However, meal benefits, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and several other services are not covered.
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