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)
- 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):
- 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 Evidence of Coverage (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 preventive 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 $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.