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To file an appeal or grievance for your medical benefit coverage or your prescription drug coverage, contact Keystone 65 Customer Service at 1-800-645-3965 or Personal Choice 65 Customer Service at 1-888-718-3333; TTY/TDD users should call 711, 7 days a week, 8 a.m. to 8 p.m.; or you can complete and submit online the Request for Medicare Prescription Drug Coverage Determination or the Request for Redetermination of Medicare Prescription Drug Denial.
For additional information from the Centers for Medicare and Medicaid Services (CMS) visit http://www.medicare.gov. If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form. For additional assistance, visit The Office of the Medicare Ombudsman.
Independence Blue Cross offers Medicare Advantage plans with a Medicare contract. Enrollment in Independence Medicare Advantage plans depends on contract renewal.
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.
Medicare beneficiaries may also enroll in Keystone 65 HMO, Keystone 65 HMO-POS, Personal Choice 65SM PPO, or Select Option® PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
Keystone 65 HMO and Personal Choice 65SM PPO: For accommodation of persons with special needs at meetings call toll-free 1-877-393-6733 (711 for the speech- and hearing-impaired).
Select Option® PDP: For accommodation of persons with special needs at meetings call toll-free 1-888-678-7009 (711 for the speech- and hearing-impaired).
Every year, Medicare evaluates plans based on a 5-Star rating system.
MedigapFreedom: To join, you must be enrolled in Medicare Parts A and B. Plan F and Plan N are available only to applicants who enroll within six months following enrollment in Medicare Part B or who are guaranteed the right to purchase these plans under applicable federal or state laws. You must continue to pay Medicare Part A (if applicable) and Part B premiums.
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 six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six-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.
Not connected with or endorsed by the U.S. Government or the federal Medicare program.
MedigapFreedom Individual plans: Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association.
MedigapSecurity plans are offered through Independence Blue Cross and Highmark Blue Shield, independent licensees of the Blue Cross and Blue Shield Association.
Dental benefits are underwritten by QCC Insurance Company and Keystone Health Plan East and administered by United Concordia Companies, Inc., an independent company.
One Day University is an independent company.
The grocery benefit mentioned is a part of special supplemental program for the chronically ill. Not all members qualify.
The meals program benefit mentioned is a part of special supplemental program for the chronically ill. Not all members qualify.
The One Pass fitness benefit is a program provided by Rally Health, Inc. an independent company. ©2022 Rally Health, Inc. Rally, the Rally logo(s) and One Pass are trademarks of Rally Health, Inc. and/or its affiliates.
TruHearing® is a registered trademark of TruHearing, Inc., an independent company.
Telemedicine is provided through MDLIVE, by Evernorth, an independent company. MDLIVE 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-of-use/.
Out-of-network/non-contracted providers are under no obligation to treat Independence Blue Cross Medicare members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Dual-purpose items are medicines and products that can be used for either a medical condition or for general health and well-being. In order to purchase these items under your plan, your personal physician must recommend them to you for a specific diagnosed condition. Please speak to and confirm with your physician before ordering these items. Items include, but are not limited to, vitamins and minerals, home monitoring and testing, and weight loss items.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2024, and from time to time during the year.
Independence Blue Cross has contracted with New Ocean Health Solutions, an independent company, to manage the Independence health rewards program for Independence Blue Cross members. New Ocean Health Solutions has subcontracted with Tango Card, Inc., an independent company, to manage the gift card service related to the Independence health rewards program. Offer only for eligible Medicare Advantage beneficiaries who completed a health care activity, may not be redeemed for cash (unless required by law). Tango Card, Inc. at its discretion may substitute a gift card of the same value. Terms and conditions may apply for this rewards program. To learn more, visit rewardsgenius.com/reward-link-terms-of-service. Independence Blue Cross, New Ocean Health Solutions, and Tango Card, Inc., are not affiliated with the gift card companies. Please see gift card for terms and conditions of use.
