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2019 2021
Smart Solutions Brochure Smart Solutions Brochure
Y0041_HM_21_89920_M
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Hi, Neighbor! We would like to thank you for considering a Medicare plan with Independence Blue Cross (Independence). Our mission is to enhance the health and well-being of the people and communities we serve. We achieve this by working closely with you and your provider to ensure you get the care you need, when you need it most. We understand the importance of good health — and we would like to show you all the ways your Independence Blue Cross Medicare plan can help you protect it. This booklet is designed for you and will help you understand: 1. Why Independence has great plans for people on Medicare 2. Benefit highlights 3. How to enroll, plus information about the provider and pharmacy finder 4. What to expect after you enroll
Thank you for giving us the opportunity to show you the Benefit of BlueSM so you can live at your best. At Independence, we care for our members like our friends and neighbors — because they are. Best of Health,
Heidi J. Syropoulos, MD, FACP Medical Director, Government Markets
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IN THIS SECTION:
Benefits at a Glance
Enjoy the doctors and hospitals of your choice with Blue's large network. We provide care, value, security and protection. • Three $0 premium plans • No medical or Rx deductibles • No referrals • $0 primary care copays for all network doctors and on all HMO plans • $0 copay for telemedicine medical doctor visits • Plans with up to $60 quarterly, over-the-counter allowance to spend at major retailers • $1 preferred generics at select pharmacies Plus special benefits for in-network COVID-19 testing and treatment throughout 2021!
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Coverage you can count on
Independence Blue Cross offers an over-the-counter allowance on ALL of our 2021 Medicare Advantage plans. Over-the-counter items • Benefit card
Members receive a benefit card. Once they activate it online or by phone, members can use their card to purchase eligible over-the-counter items with their allowance. • Retail locations
Now, members can use their over-the-counter benefit card at participating retail locations like CVS, Walgreens, Walmart, Rite Aid, Dollar General, Family Dollar, Giant, and more. • Benefits at their fingertips!
Members can track their balances and find eligible items and discounts from their smartphones. The OTC Network® Mobile App puts rewards at their fingertips 24/7.
COVID-19 coverage All of our Medicare Advantage plans offer complete coverage for in-network COVID-19 testing. • Our plans also include a $0 copayment for diagnostic testing for in-network HMO and PPO members, and members who are admitted to the hospital with a COVID-19 diagnosis will be charged a $0 copayment for their in-network inpatient hospital stay. PPO members who use out-of-network benefits may have a higher cost-share.
Telemedicine benefit offered through MDLIVE Plan members get 24/7 access to a doctor over the phone or online for a $0 copay. • Members also have access to behavioral health visits, including therapy and counseling services, for a $5 copay.
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Get healthy, get rewarded
Independence Health Rewards As a Keystone 65 HMO or Personal Choice 65SM PPO member, you may be eligible for gift cards from some of your favorite retailers when you complete annual preventive screenings and other health activities. The more you complete, the more you are eligible to earn! Please visit ibxmedicare.com/rewards for additional program details. SilverSneakers®* fitness program With our exclusive Medicare Advantage membership: • Enjoy access to classes, pools, free weights, treadmills, and more. • Access to more than 13,000 fitness locations nationwide at no extra cost. • Expand your circle of friends and enjoy social activities. • Take advantage of specialized fitness classes.
Personal health visit
Schedule a personal health visit with a licensed professional and receive a $50 gift card! Personal health visits are a convenient way to get personalized health advice in a relaxed setting, and they are offered to you at no extra cost. This service is optional, does not affect your current health insurance benefits or premiums, and does not replace your annual wellness visit.
$0 copay preventive services
Preventive screenings are vital to keeping you healthy and happy. With an Independence Medicare Advantage plan, you are covered for more than 20 preventive services — at no cost to you!* $0 preventive services include an annual wellness visit and certain immunizations; colorectal, breast and prostate cancer screenings; and cardiovascular disease and diabetes screenings.
If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment depends on the provider type or place of service.
*
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ADDITIONAL MEMBER BENEFITS Available to Keystone 65 HMO Members! Vital Care, Vital Care Plus and Manna Meal Benefits
Vital Care •A vailable on Keystone 65 Basic, Keystone 65 Focus (Chester, Delaware, and Montgomery counties), Keystone 65 Select and Keystone 65 Preferred members who have BOTH Diabetes and Congestive Heart Failure. • $10 copay cardiology visits • $10 copay endocrinology visits • $5 copay podiatry visits • $5 copay for routine podiatry visits (up to 6 routine podiatry visits annually) Vital Care Plus •A vailable on Keystone 65 Focus (Philadelphia and Bucks counties) only for members who have diabetes. • $10 copay cardiology visits • $10 copay endocrinology visits • $10 copay pulmonology visits • $5 copay podiatry visits • $5 copay for routine podiatry visits (up to 6 routine podiatry visits annually) • $80 OTC quarterly allowance Manna Meal Program •A vailable to all Keystone 65 Plans in ALL counties for members who have Diabetes AND Congestive Heart Failure, after an inpatient hospital or Skilled Nursing Facility stay. • $0 copay • 3 meals per day, 7 days per week, up to 4 weeks, 2 x per year
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IN THIS SECTION:
Benefit & Cost Comparison
MEDICARE ADVANTAGE PLANS Service category
Monthly plan premium Primary Care Physician (PCP) Visits Specialist Visits Emergency Care (Covered worldwide)
Keystone 65 Basic Rx HMO*
K
Philadelphia and Bucks
Chester, Delaware, Montgomery
$0
$0
Medical with Rx $0 copay $40 copay; no referrals required
$ $
$90 copay; separate copay from inpatient stay (not waived if admitted) $15 copay for retail clinic; $40 copay in-network urgent care center
$ (
Routine Chiropractic and Podiatry Services§ NEW! Routine Acupuncture Ambulatory Surgical Center (ASC)/ Outpatient Hospital Inpatient Hospital (Including COVID-19 coverage)
$20 copay for Chiropractic visit (up to 6 visits per year); $25 copay for Podiatry visit (up to 6 visits per year) $20 copay for Acupuncture visit (up to 6 visits per year) $200 copay Ambulatory Surgical Center per visit $350 copay Outpatient Hospital Facility per visit $250/day for days 1–7; $1,750 maximum per admission; no copay for additional days per admission; unlimited days per admission; $0 copay for inpatient hospital stay - acute, due to COVID-19 diagnosis
Fitness Program
SilverSneakers®
$ $ $ $ $ $ $ $ f $ C S
Over-the-Counter (OTC) items1 (InComm)
$60 OTC quarterly allowance
$
Telemedicine Visits (MDLive)
$0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $5 copay for behavioral health visits focused on therapy and counseling services Included in plan! See page 13 for details
$ m f I
Preferred Retail and Mail Order 90-day supply for 2 months’ copay
Preferred Generic/$2; Generic/$20
P
Preferred Retail Cost-Sharing (30-day supply)
Preferred Generic $1/Generic $10/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug Preferred Generic $9/Generic $20/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug A maximum of $4,130 in total drug cost You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $6,550 You pay the greater of $3.70 generic and $9.20 brand or 5% coinsurance after reaching a maximum of $6,550 catastrophic trigger
P $ P $ A Y d Y 5 c
Urgent Care (Covered worldwide)**
Dental/Vision/Hearing
Prescription drugs
Standard Retail Cost-Sharing (30-day supply) Initial Coverage Limit Coverage Gap Catastrophic
Quarterly OTC allowance does not carry over. The maximum out-of-pocket for 2021 is $7,550 for Keystone 65 Basic, $6,500 for Keystone 65 Focus, and $4,900 for Keystone 65 Select. *All Keystone 65 Basic, Keystone 65 Preferred, and Keystone 65 Select members must use in-network hospitals and physicians with the exception of emergencies or urgently needed care. §Routine Chiropractic and Podiatry visits are in addition to Medicare-covered services. 1
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s;
Keystone 65 Select HMO*
Keystone 65 Focus Rx HMO-POS‡ Philadelphia and Bucks Medical with Rx
Chester, Delaware, Montgomery
$0
$15.00
Medical only Medical with Rx
Philadelphia and Bucks $34.50 $56.50
Chester, Delaware, Montgomery $49.50 $82.50
$0 copay $40 copay; no referrals required
$0 copay $40 copay; no referrals required
$90 copay; separate copay from inpatient stay (not waived if admitted)
$90 copay; separate copay from inpatient stay (not waived if admitted)
$10 copay for retail clinic; $40 copay in-network urgent care center $20 copay for Chiropractic visit (up to 6 visits per year); $25 copay for Podiatry visit (up to 6 visits per year) $20 copay for Acupuncture visit (up to 6 visits per year) $200 copay Ambulatory Surgical Center per visit $325 copay Outpatient Hospital Facility per visit $210/day for days 1–6; $1,260 maximum per admission; no copay for additional days per admission; unlimited days per admission $0 copay for inpatient hospital stay - acute, due to COVID-19 diagnosis SilverSneakers®
$15 copay for retail clinic; $40 copay in-network urgent care center $20 copay for Chiropractic visit (up to 6 visits per year); $20 copay for Podiatry visit (up to 6 visits per year) $20 copay for Acupuncture visit (up to 6 visits per year) $200 copay Ambulatory Surgical Center per visit $350 copay Outpatient Hospital Facility per visit $250/day for days 1–6; $1,500 maximum per admission; no copay for additional days per admission; unlimited days per admission $0 copay for inpatient hospital stay - acute, due to COVID-19 diagnosis SilverSneakers®
$60 OTC quarterly allowance
$30 OTC quarterly allowance
$0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $5 copay for behavioral health visits focused on therapy and counseling services Included in plan! See page 13 for details
$0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $5 copay for behavioral health visits focused on therapy and counseling services Included in plan! See page 13 for details
Preferred Generic/$2; Generic/$20
Preferred Generic/$2; Generic/$18
Preferred Generic $1/Generic $10/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug Preferred Generic $9/Generic $20/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug A maximum of $4,130 in total drug cost You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $6,550 You pay the greater of $3.70 generic and $9.20 brand or 5% coinsurance after reaching a maximum of $6,550 catastrophic trigger
Preferred Generic $1/Generic $9/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug Preferred Generic $9/Generic $20/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug A maximum of $4,130 in total drug cost You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $6,550 You pay the greater of $3.70 generic and $9.20 brand or 5% coinsurance after reaching a maximum of $6,550 catastrophic trigger
‡Keystone 65 Focus has an annual plan level POS maximum limit of $1,000 per year. The POS benefit will apply to Medicarecovered medical (Parts A & B) benefits. **For urgently needed care received outside the United States, the Emergency Room copayment will apply. 102780_102607_IBC_2021_BROKERVERSION_SmartSolutions_Brochure_8-5x11_F2.indd 9
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MEDICARE ADVANTAGE PLANS Service category
Keystone 65 Preferred HMO* Philadelphia and Bucks $178.00 $230.00
Chester, Delaware, Montgomery $194.00 $258.00
Monthly plan premium
Medical only Medical with Rx
Primary Care Physician (PCP) Visits
$0 copay
Specialist Visits
$40 copay; no referrals needed
Emergency Care (Covered worldwide)
$90 copay; separate copay from inpatient stay (not waived if admitted)
Urgent Care (Covered worldwide)** Routine Chiropractic Services and Podiatry Services‡ NEW! Routine Acupuncture Ambulatory Surgical Center (ASC)/ Outpatient Hospital
$5 copay for retail clinic; $40 copay for in-network urgent care center $20 copay for Chiropractic visit (up to 6 visits per year); $20 copay for Podiatry visit (up to 6 visits per year) $20 copay for Acupuncture visit (up to 6 visits per year)
Inpatient Hospital (Including COVID-19 coverage)
$225/day for days 1–6; $1,350 maximum per admission; no copayment for additional days per admission; unlimited days per admission $0 copay for inpatient hospital stay - acute, due to COVID-19 diagnosis
Fitness Program Over-the-Counter (OTC) items1 (InComm) Telemedicine Visits (MDLive)
SilverSneakers® $30 OTC quarterly allowance $0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $5 copay for behavioral health visits focused on therapy and counseling services $0 copay for routine dental; one exam and cleaning once every six months / 1 bitewing X-ray per year, 1 periapical x-ray every 3 years, 1 full mouth/panoramic x-ray every 3 years; $10 copay for a routine eye exam and up to $200 allowance for glasses and lenses every year when purchased from Visionworks, $150 allowance every year for eyewear (including contact lenses) at a Davis Vision provider. $10 copay for a routine hearing exam every year; Hearing aid benefit copay of $499 for standard digital hearing aid or $799 for premium digital hearing aid (including rechargeable option) per hearing aid (one per ear/per year) provided through TruHearing
Routine Dental Care Routine Vision Care
Routine Hearing Services
$125 copay Ambulatory Surgical Center per visit $350 copay Outpatient Hospital Facility per visit
Prescription drugs (optional) Preferred Retail and Mail Order 90-day supply for 2 months’ copay
Preferred Generic/$2; Generic/$18
Preferred Retail Cost-Sharing (30-day supply)
Preferred Generic $1/Generic $9/Preferred Brand $47/ Non-Preferred drug $100/33% coinsurance specialty drug
Standard Retail Cost-Sharing (30-day supply)
Preferred Generic $9/Generic $20/Preferred Brand $47/ Non-Preferred drug $100/33% coinsurance specialty drug
Initial Coverage Limit
A maximum of $4,130 in total drug cost You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $6,550
Coverage Gap
You pay the greater of $3.70 generic and $9.20 brand or 5% coinsurance after reaching $6,550 catastrophic trigger 1 Quarterly OTC allowance does not carry over. Keystone 65 Preferred has a $4,000 out-of-pocket maximum for 2021. The maximum out-of-pocket is the amount that you will have to pay for care during the year. This does not include your premium, just out-of-pocket costs, such as copays and coinsurance. *All Keystone 65 Preferred members must use in-network hospitals and physicians with the exception of emergent or needed care—until your plan year renews. 10 urgently ‡ Routine Chiropractic and Podiatry visits are in addition to Medicare-covered services. Catastrophic
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g
Service category
Personal Choice 65SM Prime PPO* Medical with Rx
Monthly plan premium Primary Care Physician (PCP) Visits Specialist Visits Emergency Care (Covered worldwide) Urgent Care (Covered worldwide)** Visitor/Traveler Benefit
Routine Chiropractic and Podiatry Services‡ NEW! Routine Acupuncture Ambulatory Surgical Center (ASC)/ Outpatient Hospital Inpatient Hospital (Including COVID-19 coverage) Fitness Program Over-the-Counter (OTC) items1 (InComm) Telemedicine Visits (MDLive) Dental/Vision/Hearing
Philadelphia and Bucks $0
Chester, Delaware, Montgomery $0
$5 copay $40 copay $90 copay; separate copay from inpatient stay (not waived if admitted) $10 copay for retail clinic; $40 copay for urgent care center Personal Choice 65 PPO members can use their health plan benefits in the Medicare Advantage service areas of Independence Blue Cross/ Blue Shield Plans in 37 participating states and Puerto Rico when they travel at the in-network benefit level. $20 copay for Chiropractic visit (up to 6 visits per year); $25 copay for Podiatry visit (up to 6 visits per year) $20 copay for Acupuncture visit (up to 6 per year) $245 copay Ambulatory Surgical Center per visit $375 copay Outpatient Hospital Facility per visit $250/day for days 1–7; unlimited days per admission $0 copay for inpatient hospital stay - acute, due to COVID-19 diagnosis SilverSneakers® $60 OTC quarterly allowance $0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $5 copay for behavioral health visits focused on therapy and counseling services Included in plan! See page 13 for details
Prescription drugs Preferred Retail and Mail Order 90-day supply for 2 months’ copay
Preferred Generic/$2; Generic/$20
Preferred Retail Cost-Sharing (30-day supply)
Preferred Generic $1/Generic $10/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug
Standard Retail Cost-Sharing (30-day supply)
Preferred Generic $9/Generic $20/Preferred Brand $47/Non-Preferred drug $100/33% coinsurance specialty drug
Initial Coverage Limit
A maximum of $4,130 in total drug cost
Coverage Gap
You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $6,550
Catastrophic
You pay the greater of $3.70 generic and $9.20 brand or 5% coinsurance after reaching $6,550 catastrophic trigger
Quarterly OTC allowance does not carry over. The in-network maximum out-of-pocket for 2021 is $7,550 for Personal Choice 65 Prime and $5,000 for Personal Choice 65. The combined in-network/out-of-network maximum out-of-pocket is $11,300 for Personal Choice 65 Prime and $10,000 for Personal Choice 65. *For out-of-network benefits, there is 40% coinsurance for Personal Choice 65 Prime for most covered services. **For urgently needed care outside of the United States, the Emergency Room copayment will apply. ‡ Routine Chiropractic and Podiatry visits are in addition to Medicare-covered services.
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MEDICARE ADVANTAGE PLANS Service category
Personal Choice 65SM PPO* Medical only Medical with Rx
Philadelphia and Bucks $184.00 $290.00
Chester, Delaware, Montgomery N/A $161.00
Monthly plan premium Primary Care Physician (PCP) Visits Specialist Visits Emergency Care (Covered worldwide) Urgent Care (Covered worldwide)**
$5 copay $35 copay; no referrals needed $90 copay; separate copay from inpatient stay (not waived if admitted) $5 copay for retail clinic; $40 copay for urgent care center
Visitor/Traveler Benefit
Personal Choice 65 PPO members can use their health plan benefits in the Medicare Advantage service areas of Independence Blue Cross/ Blue Shield Plans in 37 participating states and Puerto Rico when they travel at the in-network benefit level. $20 copay for Chiropractic visit (up to 6 visits per year); $20 copay for Podiatry visit (up to 6 visits per year) $20 copay or Acupuncture visit (up to 6 visits per year) $150 copay Ambulatory Surgical Center per visit $300 copay Outpatient Hospital Facility per visit $240/day for days 1–6; $1,440 maximum per admission ; no copayment for additional days per admission ; unlimited days per admission $0 copay for inpatient hospital stay - acute, due to COVID-19 diagnosis SilverSneakers®
Routine Chiropractic and Podiatry Services§ NEW! Routine Acupuncture Ambulatory Surgical Center (ASC)/ Outpatient Hospital Inpatient Hospital (Including COVID-19 coverage) Fitness Program Over-the-Counter (OTC) items1 (InComm) Telemedicine Visits (MDLive) Dental/Vision/Hearing
$30 OTC quarterly allowance $0 copay for medical doctor visits focused on non-urgent medical conditions; NEW! $5 copay for behavioral health visits focused on therapy and counseling services Included in plan! See page 13 for details
Prescription drugs (optional) Preferred Retail and Mail Order 90-day supply for 2 months’ copay
Preferred Generic/$2; Generic/$18
Preferred Retail Cost-Sharing (30-day supply)
Preferred Generic $1/Generic $9/Preferred Brand $47/ Non-Preferred drug $100/33% coinsurance specialty drug
Standard Retail Cost-Sharing (30-day supply)
Preferred Generic $9/Generic $20/Preferred Brand $47/ Non-Preferred drug $100/33% coinsurance specialty drug
Initial Coverage Limit
A maximum of $4,130 in total drug cost
Coverage Gap
You pay 25% of generic drug costs and 25% of brand-name drug costs until you reach a maximum of $6,550
Catastrophic
You pay the greater of $3.70 generic and $9.20 brand or 5% coinsurance after reaching $6,550 catastrophic trigger
Quarterly OTC allowance does not carry over. *For out-of-network benefits, there is 30% coinsurance for Personal Choice 65 PPO for most covered services. **For urgently needed care outside of the United States, the Emergency Room copayment will apply. 12 § Routine Chiropractic and Podiatry visits are in addition to Medicare-covered services. 1
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New for 2021! Dental, Vision, and Hearing Care Included in Plan Dental Care‡ Provider Network Routine exams/cleanings copay Dental X-ray copay
No Primary Dental Office (PDO) selection required** $0 copay; cleaning once every six months $0 copay; one set bitewing X-rays per year, one periapical X-ray every 3 years, one full mouth/panoramic X-ray every 3 years
Comprehensive Dental Keystone 65 Basic, Keystone 65 Focus & Keystone 65 Select
$2,000 in-network allowance every year for comprehensive dental services; 20% coinsurance for fillings and extractions; 40% coinsurance for dentures, partials, root canals, crowns, and some oral surgery;
Personal Choice 65 Prime and Personal Choice 65 PPO
$1,500 combined in-network/out-of-network allowance every year for comprehensive dental services; 20% coinsurance for fillings and extractions; 40% coinsurance for dentures, partials, root canals, crowns, and some oral surgery
Routine Vision Care‡ Provider Network Routine eye exam copay Frames, lenses, and contact lenses Eyewear doesn’t include tints, progressives, transition lenses, polish, and insurance.
Available for all Keystone 65 and Personal Choice Plans Must use Davis Vision network provider $10; one routine eye exam every year Covered each year with first year coverage. One (1) pair of eyeglass frames and lenses or one (1) pair of contact lenses. Includes: eyeglasses/frames from the Davis Vision Collection covered in full. $200 allowance for eyewear purchased from Visionworks; $150 allowance for all other eyewear purchased at a Davis Vision network provider. $150 allowance for contact lenses purchased in lieu of frames and lenses.
Routine Hearing Services† Routine hearing exam copay Hearing aid fitting and evaluations copay Keystone 65 Basic, Keystone 65 Focus, and Personal Choice 65 Prime
$10; one routine hearing exam per year $0 copay; three hearing aid fittings and evaluations per year $699 copay for a standard digital hearing aid; $999 copay for a premium digital hearing aid; up to two hearing aids every year, one hearing aid per ear
Keystone 65 Preferred, Keystone 65 Select, and Personal Choice 65 PPO
$499 copay for a standard digital hearing aid; $799 copay for a premium digital hearing aid; up to two hearing aids every year, one hearing aid per year
**Members must use a United Concordia network dental provider. †Hearing services and aids are only covered when provided by TruHearing providers. ‡For out-of-network benefits on Personal Choice 65 PPO, there is an 80% coinsurance for most dental and vision benefits.
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MEDICARE SUPPLEMENT PLANS Your MedigapFreedom Plan Choices Service Category
Plan A
Plan B
Medicare pays:
Plan G/ Plan G High Deductible* You pay:
Primary Care Physician Visits Specialist Visits Emergency Room Urgent Care
80% of Medicare-approved amounts after $203† annual Part B deductible is met
$203† Part B deductible (Plan pays 20% coinsurance)
$203† Part B deductible; up to a $20 copay for doctor visits; up to a $50 copay for emergency room (waived if admitted) (Plan pays all other Part B coinsurance)
Outpatient Surgery
All charges except $1,484† (Part A deductible) and Part A coinsurance
$1,484† (Part A deductible)
$0
$0
$0
Part B Excess Charges‡
Nothing
100%
100%
100%
Nothing
Prescription Drugs (Part D)
Nothing
Inpatient Hospital
14
Plan N
Prescription Drug coverage is not included
MedigapFreedom: COVERED PERSON means a Medicare beneficiary who is enrolled in Medicare Part A and Part B, made the appropriate payment in consideration for this Policy, and is eligible for benefits under this Policy. Non-Tobacco rates apply to applications submitted during the 6-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the 6-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates. All rates are subject to change with the approval of the Pennsylvania Insurance Department. Any rate change will apply to all policies in our service area and cannot be changed or canceled because of poor health. QCC Insurance Company has the right to change premiums based on your attained age and the table of rate changes. We will give a 30-day notice of a premium change. Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company — independent licensees of the Blue Cross and Blue Shield Association. To join, you must be enrolled in Medicare Parts A and B. You must continue to pay Medicare Part A (if applicable) and Part B premiums. *Plan G High Deductible requires first paying a plan deductible of $2,370 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plan G counts your payment of the Medicare Part B deductible toward meeting the plan deductible. The calendar year deductible is subject to change in 2022. †This is the 2021 amount and may change on January 1, 2022. Each year, Social Security notifies all Medicare beneficiaries of the new Part A deductible and coinsurance, Part B deductible, and Part B premium amount. ‡If the amount a doctor or other health care provider charges is higher than the Medicare-approved amount, the difference is called the excess charge.
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MedigapFreedom NON-TOBACCO PREMIUMS Male Non-Tobacco Premiums Plan A
Plan B
Plan G
Plan G-HD
Plan N
$131.08
$159.06
$181.55
$68.15
$139.97
$131.08
$159.06
$181.55
$68.15
$137.04
$166.30
$189.66
$142.65
$173.10
$148.61
Female Non-Tobacco Premiums Plan A
Plan B
Plan G
Plan G-HD
Plan N
Under 65*
$119.16
$144.60
$165.05
$61.95
$127.25
$139.97
65–67
$119.16
$144.60
$165.05
$61.95
$127.25
$71.25
$146.69
68
$124.58
$151.18
$172.42
$64.77
$133.35
$197.09
$74.16
$153.02
69
$129.68
$157.36
$179.17
$67.42
$139.11
$180.33
$206.04
$77.26
$160.62
70
$135.10
$163.94
$187.31
$70.24
$146.02
$154.93
$188.01
$214.99
$80.55
$168.22
71
$140.85
$170.91
$195.45
$73.23
$152.93
$160.42
$194.66
$222.93
$83.40
$174.93
72
$145.84
$176.97
$202.67
$75.82
$159.03
$165.31
$200.60
$231.38
$85.94
$182.41
73
$150.28
$182.36
$210.34
$78.13
$165.82
$169.48
$205.66
$238.64
$88.11
$188.74
74
$154.08
$186.97
$216.94
$80.10
$171.58
$174.02
$211.16
$246.58
$90.47
$195.83
75
$158.20
$191.97
$224.16
$82.24
$178.03
$177.60
$215.50
$253.67
$92.33
$202.04
76
$161.45
$195.91
$230.61
$83.94
$183.67
$181.29
$219.99
$261.95
$94.25
$209.39
77
$164.81
$199.99
$238.13
$85.68
$190.35
$185.71
$225.35
$271.40
$96.55
$218.00
78
$168.82
$204.86
$246.73
$87.77
$198.18
$188.21
$228.39
$277.65
$97.85
$223.58
79
$171.10
$207.62
$252.41
$88.95
$203.25
$189.40
$229.83
$283.39
$98.47
$228.77
80
$172.18
$208.94
$257.63
$89.52
$207.97
$192.27
$233.31
$293.02
$99.96
$237.76
81
$174.79
$212.10
$266.38
$90.87
$216.15
$195.01
$236.64
$303.66
$101.38
$247.64
82
$177.28
$215.12
$276.05
$92.17
$225.13
$195.49
$237.21
$311.09
$101.63
$254.74
83
$177.71
$215.65
$282.81
$92.39
$231.58
$195.61
$237.36
$318.02
$101.69
$261.45
84
$177.82
$215.78
$289.11
$92.45
$237.68
$197.18
$239.27
$324.60
$102.05
$267.91
85
$179.26
$217.52
$295.09
$92.77
$243.55
$200.98
$243.88
$330.85
$104.02
$274.24
86
$182.71
$221.71
$300.77
$94.56
$249.31
$205.29
$249.11
$337.94
$106.25
$281.08
87
$186.63
$226.46
$307.22
$96.59
$255.53
$207.54
$251.85
$341.66
$107.41
$284.63
88
$188.68
$228.95
$310.60
$97.65
$258.76
$210.73
$255.71
$346.90
$109.06
$290.08
89
$191.57
$232.46
$315.36
$99.15
$263.71
$215.34
$261.31
$354.50
$111.45
$297.93
90
$195.77
$237.55
$322.27
$101.32
$270.85
$220.88
$268.03
$363.62
$114.32
$306.92
91
$200.80
$243.66
$330.56
$103.92
$279.02
$221.31
$268.55
$372.74
$114.54
$315.79
92
$201.19
$244.13
$338.85
$104.12
$287.08
$228.88
$277.74
$376.79
$118.46
$319.97
93
$208.08
$252.49
$342.54
$107.69
$290.88
$231.86
$281.35
$381.69
$120.00
$324.91
94
$210.78
$255.77
$346.99
$109.09
$295.37
$234.83
$284.96
$386.58
$121.54
$329.73
95
$213.49
$259.06
$351.44
$110.49
$299.75
$237.40
$288.07
$390.81
$122.87
$334.16
96
$215.82
$261.89
$355.28
$111.70
$303.78
$241.30
$292.80
$397.22
$124.88
$340.62
97
$219.36
$266.19
$361.11
$113.53
$309.65
$244.58
$296.79
$402.63
$126.58
$346.07
98
$222.35
$269.81
$366.03
$115.08
$314.61
$247.86
$300.77
$408.03
$128.28
$351.51
99+
$225.33
$273.43
$370.94
$116.62
$319.56
To join, you must be enrolled in Medicare Parts A and B. You must continue to pay Medicare Part A (if applicable) and Part B premiums. Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association. *This includes people under 65 on Medicare due to disability.
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MedigapFreedom TOBACCO PREMIUMS Male Tobacco Premiums
Female Tobacco Premiums
Plan A
Plan B
Plan G
Plan G-HD
Plan N
Plan A
Plan B
Plan G
Plan G-HD
Plan N
$144.19
$174.97
$199.71
$74.96
$153.97
Under 65*
$131.08
$159.06
$181.55
$68.15
$139.97
$144.19
$174.97
$199.71
$74.96
$153.97
65–67
$131.08
$159.06
$181.55
$68.15
$139.97
$150.75
$182.93
$208.63
$78.37
$161.35
68
$137.04
$166.30
$189.66
$71.25
$146.69
$156.91
$190.41
$216.80
$81.58
$168.32
69
$142.65
$173.10
$197.09
$74.16
$153.02
$163.47
$198.37
$226.65
$84.99
$176.68
70
$148.61
$180.33
$206.04
$77.26
$160.62
$170.43
$206.81
$236.49
$88.60
$185.04
71
$154.93
$188.01
$214.99
$80.55
$168.22
$176.46
$214.13
$245.23
$91.74
$192.43
72
$160.42
$194.66
$222.93
$83.40
$174.93
$181.84
$220.66
$254.51
$94.54
$200.65
73
$165.31
$200.60
$231.38
$85.94
$182.41
$186.43
$226.23
$262.50
$96.92
$207.61
74
$169.48
$205.66
$238.64
$88.11
$188.74
$191.42
$232.28
$271.23
$99.52
$215.42
75
$174.02
$211.16
$246.58
$90.47
$195.83
$195.35
$237.05
$279.04
$101.56
$222.25
76
$177.60
$215.50
$253.67
$92.33
$202.04
$199.42
$241.99
$288.14
$103.68
$230.33
77
$181.29
$219.99
$261.95
$94.25
$209.39
$204.28
$247.88
$298.54
$106.20
$239.80
78
$185.71
$225.35
$271.40
$96.55
$218.00
$207.03
$251.22
$305.42
$107.63
$245.93
79
$188.21
$228.39
$277.65
$97.85
$223.58
$208.34
$252.82
$311.73
$108.32
$251.65
80
$189.40
$229.83
$283.39
$98.47
$228.77
$211.49
$256.64
$322.32
$109.95
$261.54
81
$192.27
$233.31
$293.02
$99.96
$237.76
$214.51
$260.30
$334.03
$111.52
$272.41
82
$195.01
$236.64
$303.66
$101.38
$247.64
$215.03
$260.94
$342.20
$111.79
$280.21
83
$195.49
$237.21
$311.09
$101.63
$254.74
$215.17
$261.09
$349.82
$111.86
$287.59
84
$195.61
$237.36
$318.02
$101.69
$261.45
$216.90
$263.20
$357.06
$112.26
$294.70
85
$197.18
$239.27
$324.60
$102.05
$267.91
$221.08
$268.27
$363.94
$114.42
$301.67
86
$200.98
$243.88
$330.85
$104.02
$274.24
$225.82
$274.02
$371.74
$116.87
$309.19
87
$205.29
$249.11
$337.94
$106.25
$281.08
$228.30
$277.03
$375.83
$118.16
$313.09
88
$207.54
$251.85
$341.66
$107.41
$284.63
$231.80
$281.28
$381.59
$119.97
$319.09
89
$210.73
$255.71
$346.90
$109.06
$290.08
$236.88
$287.44
$389.95
$122.59
$327.72
90
$215.34
$261.31
$354.50
$111.45
$297.93
$242.97
$294.83
$399.98
$125.75
$337.62
91
$220.88
$268.03
$363.62
$114.32
$306.92
$243.44
$295.40
$410.01
$125.99
$347.37
92
$221.31
$268.55
$372.74
$114.54
$315.79
$251.77
$305.51
$414.47
$130.30
$351.97
93
$228.88
$277.74
$376.79
$118.46
$319.97
$255.05
$309.49
$419.86
$132.00
$357.40
94
$231.86
$281.35
$381.69
$120.00
$324.91
$258.32
$313.46
$425.24
$133.69
$362.70
95
$234.83
$284.96
$386.58
$121.54
$329.73
$261.14
$316.88
$429.89
$135.15
$367.58
96
$237.40
$288.07
$390.81
$122.87
$334.16
$265.43
$322.08
$436.95
$137.37
$374.68
97
$241.30
$292.80
$397.22
$124.88
$340.62
$269.04
$326.47
$442.89
$139.24
$380.67
98
$244.58
$296.79
$402.63
$126.58
$346.07
$272.65
$330.85
$448.84
$141.11
$386.66
99+
$247.86
$300.77
$408.03
$128.28
$351.51
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IN THIS SECTION:
Ready to Enroll?
Choose the right plan for you
When enrolling in a Medicare Advantage plan, it's important to check the plan's network and formulary to see if your doctor or drug is covered. HOW TO FIND A NETWORK PROVIDER OR PHARMACY
1. To find a provider, go to ibxmedicare.com/providerfinder.
2. You can search for a specific health plan by clicking the drop-down box under Your Plan and selecting Medical. 3. Select the health plan network you would like to search. You can narrow your search by typing in a location (i.e., city or ZIP code) as well as by searching for a specific doctor, hospital, specialty, or condition. You can easily sort and refine your results by: • Specialty •P referred primary care physician (PCP) • Quality recognitions
• Providers • Languages spoken • Admitting privileges
• Facilities • Board certifications • Gender
1. To find a pharmacy, go to ibxmedicare.com/pharmacyfinder.
2. E nter terms to search for pharmacy names. You can narrow your search by entering your city, state, or ZIP code. 3. E ach pharmacy result is listed as a Preferred or Standard pharmacy. You can sort and refine your results by: • Open 24 hours • Durable • Prescription compound services medical equipment • Drive-up services • Prescription delivery
HOW TO FIND OUT IF A DRUG IS ON THE FORMULARY
1. Go to ibxmedicare.com/formulary.
2. Click on your type of health coverage (i.e., individual or group), and then select the plan’s name.
18
3. Once the drug search tool opens, you can search the formulary alphabetically by drug name or by therapeutic class.
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Keystone 65 Focus HMO gives you affordable access to a select network of 23,000 providers and 20 hospitals in the Independence Blue Cross network. 1. Abington Memorial Hospital 2. Aria Hospital - Bucks County 3. Aria Hospital - Frankford 4. Aria Hospital - Torresdale 5. Brandywine Hospital 6. Chestnut Hill Hospital 7. Doylestown Hospital 8. Grand View Hospital 9. Holy Redeemer Hospital 10. Jennersville Regional Hospital 11. Lansdale Hospital 12. Bryn Mawr Hospital - Main Line Health 13. Lankenau Medical Center - Main Line Health 14. Paoli Hospital - Main Line Health 15. Riddle Hospital - Main Line Health 16. Methodist Hospital - TJUH 17. Phoenixville Hospital 18. Pottstown Memorial Medical Hospital 19. St Luke’s Hospital - Quakertown 20. Thomas Jefferson University Hospital For a complete list of providers, visit www.ibxmedicare.com.
Questions? Call Independence Blue Cross at
1-877-393-6733 (TTY/TDD:711)
Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail. Or visit us online at www.ibxmedicare.com
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After You Enroll
After you enroll, use this checklist to keep track of your new plan. You will hear from us within approximately 30 days of your acceptance into the plan.
Enrollment Checklist
What to expect from your plan:
Material Name
Description
Plan confirmation/ acceptance letter
We will send you a letter within 10 days of the Centers for Medicare & Medicaid Services' approval of your enrollment.
Enrollment verification letter
An enrollment verification letter is required for enrollment requests received by an individual assisted by an independent or employed agent/broker who provided plan-specific information to the individual.
New member welcome kit
Your bill
Received
This kit contains your Evidence of Coverage (EOC) — a complete description of your Medicare plan coverage and your rights as a member. It also contains a drug formulary (if applicable) and other important forms, such as electronic billing and mail order sign-up. We generate premium bills each month. If you have a plan with a premium and you signed up for your plan early in the month, you may get your first bill before your plan’s start date. If you signed up later in the month, your first bill may include two months of premiums. (Our billing cycle factors in one month’s premium in advance). To join one of our plans, you’ll need to continue paying your Medicare Part A and/or Part B premiums (if not otherwise paid for under Medicaid or another third party). This is in addition to your Independence Blue Cross Medicare plan coverage.
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Material Name
Description
Received
Member ID card
Use your Independence Blue Cross member ID card (not your Medicare card) every time you visit the doctor, hospital, or pharmacy (if you have prescription coverage). Make sure your PCP is on the card or call our Member Help Team to have him/her added. You will receive your ID card after you receive your confirmation letter.
Personalized health advice
Personal Health Visits are visits from a nurse practitioner in your home or at other partner center locations. This visit lasts about an hour and includes a brief health assessment. It is a helpful and convenient way to get personalized health advice in a relaxed setting, and is offered to you at no extra cost. This service is optional, and the visit will not affect your current health insurance benefits or premiums. You will receive a call from one of our health care partners to see if you’re interested in scheduling a visit.
Doctor visit
Take advantage of your annual wellness visit, which is covered by Medicare without a copay or coinsurance. It’s a great opportunity for you and your doctor to review your medical history, identify risk factors to your health, and discuss a plan to prevent illness and improve your health in the future.
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Medical Exclusions • Personal items in your room at a hospital or skilled nursing facility • Full-time nursing care in your home • Custodial care is care provided in a nursing home, hospice or other facility setting when you do not require skilled medical care or skilled nursing care*
• Home-delivered meals** • Reversal of sterilization procedures and/ or non-prescription contraceptive supplies • Naturopath services (uses natural or alternative treatments)
• Homemaker services, including housekeeping or light meal preparation • Fees charged for care by your immediate relatives or members of your household
Part D Exclusions
Also, by law, these categories of drugs are not covered by Medicare drug plans: • Non-prescription drugs (also called over-the-counter drugs)
• Drugs when used for the treatment of sexual or erectile dysfunction
• Drugs when used to promote fertility
• Drugs when used for the treatment of anorexia, weight loss, or weight gain
• Drugs when used for the relief of cough or cold symptoms • Drugs when used for cosmetic purposes or to promote hair growth • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale
* Custodial care is personal care that does not require the continuing attention of trained medical or paramedic personnel, such as care that helps you with activities of daily living, such as bathing or dressing. ** Offered on HMO plans only. Visit www.ibxmedicare.com for a complete listing of benefits and exclusions.
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Independence Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-275-2583 (TTY/TDD: 711). 注意：如果您使用繁體中文， 您可 以免費獲得語言援助服務。 請致電 1-800-275-2583 (TTY/TDD: 711)。 The SilverSneakers fitness program is provided by Tivity Health, Inc., an independent company. ©2021. All rights reserved. MDLIVE, an independent company, may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in-person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Health care professionals using the platform have the right to deny care if, based on professional judgment, a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.mdlive.com/terms-ofuse/. The Independence Blue Cross OTC benefit is underwritten by Keystone Health Plan East/QCC Insurance Company and is administered by InComm, an independent company. Dental benefits are underwritten by Keystone Health Plan East/QCC Insurance Company and administered by United Concordia Companies, Inc., an independent company. Vision benefits are underwritten by Keystone Health Plan East/QCC Insurance Company and administered by Davis Vision, an independent company. An affiliate of Independence Blue Cross has a financial interest in Visionworks, an independent company. TruHearing is a registered trademark of TruHearing, Inc., an independent company. Independence Blue Cross offers Medicare Advantage plans with a Medicare contract. Enrollment in Independence Medicare Advantage plans depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Personal Choice 65 PPO members, except in emergency situations. Please call our Member Help Team number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. This booklet is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings. Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
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