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.

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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.
Specialist visits

$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:

  • Up to one oral exam every six months.
  • Up to one cleaning every six months.
  • Up to one fluoride treatment every six months.
  • Up to two dental X-rays every year.

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:

  • minor restorations (fillings)
  • simple extractions
  • dentures, 1 every 5 years. Prior authorization is required.
  • denture repair and reline
  • surgical extractions
  • Oral surgery
  • Periodontics
  • Endodontics
  • Crowns, 1 every 5 years, per tooth. No more than 4 per calendar year, with no more than 2 crowns per arch.
  • Mini-implants (lower arch only) and implant supported denture (lower arch only). 

*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.

  • $0 for up to 1 routine hearing exam every year
  • $0 for up to 3 fittings for a hearing aid every three years
  • $0 for 48 batteries per aid for non-rechargeable models every three years
  • $1,500 allowance for hearing aids every 3 years

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.

Vision services

$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 preventive vision benefits:

  • Up to one supplemental routine eye exam every year.
  • One pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.
  • Up to one pair of eyeglasses (lenses and frames) every year.
  • Up to one pair of contact lenses every year.

We pay up to $350 every year for contact lenses and eyeglasses (frames and lenses).

Transportation

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.
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) items Up to $365 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.

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