Summary of Benefits
You have options for your Medicare Advantage coverage. Think about your needs and what type 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, skilled nursing facilities, and home health care.
- A large network of doctors, hospitals, specialists, and pharmacies.
Plus, you'll get extra benefits, including:
- Wellness programs.
- Transportation to the doctor.
- Hearing, dental, and vision benefits.
- 24-hour nurse hotline.
- Great service and personal attention.
Questions? Call 1-800-450-1166 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31.
Below is a brief summary of key benefits.
You may also view:
- Pre-enrollment checklist (PDF).
- Summary of benefits (PDF).
- Over-the-Counter Benefit Product Catalog (OTC) (PDF).
- Review information about your over-the-counter benefits online by visiting www.keystoneflexcard.com. You can also call 1-800-400-6609 (TTY 711), Monday – Friday from 8 a.m. to 8 p.m. EST.
- Spanish Over-the-Counter Benefit Product Catalog (OTC) (PDF).
- Annual notice of changes (ANOC) (PDF):
- The ANOC tells you about all plan changes in the next year.
- Spanish ANOC (PDF).
- Evidence of Coverage (EOC) (PDF):
- 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 First VIP Choice for more information.
Find a provider in our network for the benefits 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||
Unlimited amount each year for preventive dental services.
$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).
Unlimited trips per year for health care services 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. Rides must be scheduled at least one business day in advance except in special circumstances. Transportation is authorized for plan-approved locations only (e.g. doctor's office, pharmacy and hospital).
*Prior authorization is required for trips that exceed 50 miles for a one-way ride. Other prior authorization and scheduling rules apply.
|Over-the-counter (OTC) pharmacy and Special Supplemental Benefits for the Chronically Ill (SSBCI)/Food and Produce||
Up to $315 per quarter may be spent for over-the-counter (OTC) items included in the OTC catalog (PDF), online ordering portal and/or qualified items at participating retail settings via a restricted spend debit card. Spanish OTC catalog (PDF) Members may purchase up to six products per category per quarter. There is no limit on the total number of items a member may purchase. OTC catalog and online ordering portal orders are limited to three orders per quarter. Additional limits may apply to some items.
Members with qualifying SSBCI chronic conditions may also use up to $100 of the $315 quarterly allowance towards qualifying food and produce at participating retail locations and/or FarmBox mail-order, items limits may apply. Any unused balance will automatically expire at the end of each quarter or upon disenrollment from the plan.
Refer to the Evidence of Coverage (EOC) (PDF) for more information on the qualifying SSBCI chronic conditions. The benefits mentioned are a part of special supplemental program for the chronically ill. Not all members qualify.
|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.
Important message about what you pay for vaccines
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
Important message about what you pay for insulin
You won't pay more than $35 for a one- month supply of each insulin product covered by our plan, no matter what cost sharing tier it is on. In most cases you will not pay more than $10.35 for a one-month supply of each insulin product.