Summary of Benefits
You have options for your Medicare Advantage coverage. Think about your needs and what types of benefits will help you most. Keystone First VIP Choice (HMO-SNP) offers all the benefits of regular Medicare, plus more.
Keystone First VIP Choice provides:
- $0 copay for Medicare-covered dental and vision benefits.
- Coverage for inpatient hospital care, as well as skilled nursing facility and home health care coverage.
- A large network of doctors, hospitals, specialists, and pharmacies.
- Preventive services to help you stay healthy.
- Wellness education, including smoking cessation and a nurse hotline.
- Great service and personal attention.
Below is a brief summary of key benefits
You may also view:
- A pre-enrollment checklist (PDF).
- A complete summary of benefits (PDF).
- An Over-the-Counter Benefit Product Catalog (OTC) (PDF).
- A complete annual notice of changes (ANOC) (PDF):
- The ANOC tells you about all plan changes in the next year.
- Spanish ANOC (PDF).
- A complete Evidence of Coverage (EOC) (PDF) (October 15, 2021):
- The EOC tells you how to get Medicare-covered medical care and prescription drugs through our plan. The booklet explains what's covered, how much you'll pay for services, and all about your rights and responsibilities.
- Spanish EOC (PDF).
- Or contact Keystone VIP Choice for more information.
Find a provider in our network for the benefits listed below.
|Premium||$0 monthly plan premium.|
|Doctor office visits||$0 copay for each Medicare-covered primary care provider visit.|
$0 copay for each Medicare-covered specialist visit.
No referral required.
|Preventive and comprehensive dental||
$1,000 plan coverage limit for preventive dental benefits every year.
$0 copay for the following preventive dental benefits:
The combined total comprehensive dental benefits cannot exceed $3,000 every year. The comprehensive dental benefits include the following services up to a $3,000 combined limit every year:
*Prior authorization is required for dentures, periodontics, endodontics, crowns, mini implants, and implant supported dentures. Fixed bridges and all other dental implants, except for mini-implants, are not covered.
|Hearing exams and aids||
Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.
You must receive your care from a network provider. We will only pay for covered hearing services if you go to an in-network hearing provider. In most cases, you will have to pay for care that you receive from an out-of-network provider.
$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk.
$0 copay for the following supplemental vision benefits:
We pay up to $350 every year for contact lenses and eyeglasses (frames and lenses).
Up to 100 one-way trips every year to plan-approved locations (e.g. doctor’s office, pharmacy, and hospital). May consist of a car, shuttle, or van service depending on appropriateness for the situation and the member’s needs.
|Over-the-counter (OTC) items||
Up to $300 per quarter may be spent for specific over-the-counter drugs. Get more information from the OTC catalog (PDF). Money not spent in a quarter does not roll over into the next quarter.
|Home health care||$0 copay for Medicare-covered home health visits.|
|Outpatient mental health care||
$0 copay for each Medicare-covered individual therapy visit.
$0 copay for each Medicare-covered group therapy visit.
$0 copay for each Medicare-covered individual therapy visit with a psychiatrist.
$0 copay for each Medicare-covered group therapy visit with a psychiatrist.