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Medical benefits (Part C)

Understanding your health plan is very important. Review the information below to learn about your plan's coverage and administration and make the best use of your benefits. To find out more about the benefits in your plan simply log in at ibx.com/login.

Learn more:

Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCD)

A National Coverage Determination (NCD) is a decision made through an evidence-based process of whether Medicare will pay for an item or service. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for the diagnosis or treatment of an injury or illness (and within the scope of a Medicare benefit category).

Acupuncture for chronic low back pain

On January 21, 2020, CMS released a NCD stating that Medicare will now cover acupuncture treatment for chronic low back pain.

Coverage details

  • Up to 12 visits in a 90-day period
  • Additional eight sessions covered for patients demonstrating improvement
  • No more than 20 acupuncture treatments annually

Please see the CMS definition of chronic low back pain below:

  • Pain lasting 12 weeks or longer
  • No identifiable systemic cause (disease, infection, inflammatory, etc.)
  • Not associated with surgery
  • Not associated with pregnancy

Treatment will be discontinued after the initial 12 visits if the patient is not improving or if the patient is regressing.

All types of acupuncture, including dry needling, for any condition other than chronic low back pain are not covered by Medicare.

Physician requirements

Physicians may furnish acupuncture in accordance with applicable state requirements.

Non-physician requirements

Physician assistants, nurse practitioners/clinical nurse specialists, and auxiliary personnel must meet applicable state requirements in order to provide acupuncture treatment to Medicare beneficiaries. They must also have:

  • A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and
  • Current, full, active, and unrestricted license to practice acupuncture in a state, territory, or commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.

Auxiliary personnel furnishing acupuncture must also be under the appropriate level of supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist required by CMS regulations.

Visit CMS.gov for more information on the CMS NCD.


Organization determination (coverage decision) for Part C

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. You, your physician, or your representative may make an oral or written, standard or expedited request. When we give you our decision, we will use the standard deadlines unless we have agreed to use the expedited deadlines. A standard coverage decision means we will give you an answer within 14 days after we receive your doctor's statement. A fast coverage decision means we will answer within 72 hours after we receive your doctor's statement.

If you are a Keystone 65 HMO member, you can request an organization determination by using one of the methods below.

  • Call 1-800-ASK-BLUE (1-800-275-2583) (TTY/TDD: 711).
    Calls to this number are free, 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3029.
  • Write Keystone 65 HMO
    Clinical Precertification
    1901 Market Street
    Philadelphia, PA 19103

If you are a Personal Choice 65SM PPO member, you can file an organization determination by using one of the methods below.

  • Call 1-800-ASK-BLUE (1-800-275-2583) (TTY/TDD: 711).
    Calls to this number are free, 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3029.
  • Write Personal Choice 65 PPO
    Clinical Precertification
    1901 Market Street
    Philadelphia, PA 19103

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

2021 organization determination instructions

Download 2021 organization determination instructions

For more information on Keystone 65 Medical-only HMO’s organization determination process, please reference Chapter 7, Section 4 on page 119 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Organization Determination Instructions

For more information on Keystone 65 Rx HMO’s organization determination process, please reference Chapter 9, Section 4 on page 182 in your EOC or click on the link below.

Keystone 65 Rx HMO Organization Determination Instructions

For more information on Personal Choice 65SM Medical-only PPO’s organization determination process, please reference Chapter 7, Section 4 on page 126 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Organization Determination Instructions

For more information on Personal Choice 65SM Rx PPO’s organization determination process, please reference Chapter 9, Section 4 on page 183 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Organization Determination Instructions

2020 organization determination instructions

Download 2020 organization determination instructions

For more information on Keystone 65 Medical-only HMO’s organization determination process, please reference Chapter 7, Section 4 on page 123 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Organization Determination Instructions

For more information on Keystone 65 Rx HMO’s organization determination process, please reference Chapter 9, Section 4 on page 185 in your EOC or click on the link below.

Keystone 65 Rx HMO Organization Determination Instructions

For more information on Personal Choice 65SM Medical-only PPO’s organization determination process, please reference Chapter 7, Section 4 on page 125 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Organization Determination Instructions

For more information on Personal Choice 65SM Rx PPO’s organization determination process, please reference Chapter 9, Section 4 on page 182 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Organization Determination Instructions


Prior authorization for Part C

Some of the services listed in the Medical Benefits Chart included in your Evidence of Coverage (EOC) are covered only if your doctor or other network provider gets approval in advance (sometimes called “prior authorization”) from us. Covered medical services and durable medical equipment (DME) that need approval in advance are marked in the Medical Benefits Chart by an asterisk. Your doctor or other network provider can request a medical prior authorization on your behalf. A decision on a request for prior authorization for medical services will typically be made within 72 hours of us receiving the request but can take up to 14 days, if we are waiting for information from your doctor.

2021 prior authorization for Part C

For more information on Keystone 65 Medical-Only HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 44 in your EOC or click on the link below.

Keystone 65 Medical-Only HMO Prior Authorization and Benefits Chart

For more information on Keystone 65 Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 59 in your EOC or click on the link below.

Keystone 65 Rx HMO Prior Authorization and Benefits Chart

For Personal Choice 65SM Medical-Only PPO members and Personal Choice 65SM RX PPO, some in-network medical services are covered only if your doctor or other network provider gets prior authorization from our plan. In a PPO, you do not need prior authorization to obtain out-of-network services, but you can ask the plan to make a coverage decision in advance.

For more information on Personal Choice 65SM Medical-Only PPO's prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 45 in your EOC or click on the link below.

Personal Choice 65 Medical-Only PPO Prior Authorization and Benefits Chart

For more information on Personal Choice 65SM Rx PPO's prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 55 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart

2021 prior authorization — durable medical equipment (DME)

We cover all medically necessary durable medical equipment (DME) covered by Original Medicare. Covered DME items include, but are not limited to, diabetic supplies, wheelchairs, walkers, speech-generating devices, oxygen equipment, and CPAP machines.

Items are covered as in-network only if your doctor or other network provider gets approval (also known as "prior authorization") in advance.

Be sure to talk to your doctor before ordering supplies. Your doctor may be able to order for you and provide prior authorization for in-network coverage.

For Keystone 65 Preferred, Select, and Basic members, you can use only an in-network DME supplier to order your Medicare-covered DME equipment.

For Personal Choice 65SM PPO, Personal Choice 65SM RX PPO, and Keystone 65 Focus Rx HMO-POS, you can use an in- or out-of-network DME supplier to order your Medicare-covered DME equipment, but you’ll save money by using an in-network supplier. For more information on in- and out-of-network coinsurance amounts, please reference the durable medical equipment section of the Medical Benefits Chart, durable medical equipment section in your Evidence of Coverage (EOC).

For the most recent list of DME suppliers visit ibxmedicare.com/providerfinder and search "durable medical equipment."

If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special-order it for you.

For diabetic supplies, test strips and monitors must be obtained from preferred vendors/brands Accu-Chek and OneTouch. Test strips and monitors from any other vendor will not be covered. In-network diabetic shoes and inserts, lancets, solutions, insulin pumps, and related supplies from any brand are available to members at no cost.

2020 prior authorization for Part C

For more information on Keystone 65 Medical-Only HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 45 in your EOC or click on the link below.

Keystone 65 Medical-Only HMO Prior Authorization and Benefits Chart

For more information on Keystone 65 Rx HMO’s prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 58 in your EOC or click on the link below.

Keystone 65 Rx HMO Prior Authorization and Benefits Chart

For Personal Choice 65SM PPO members, some in-network medical services are covered only if your doctor or other network provider gets prior authorization from our plan. In a PPO, you do not need prior authorization to obtain out-of-network services, but you can ask the plan to make a coverage decision in advance.

For more information on Personal Choice 65SM Medical-Only PPO's prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 43 in your EOC or click on the link below.

Personal Choice 65 Medical-Only PPO Prior Authorization and Benefits Chart

For more information on Personal Choice 65SM Rx PPO's prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 55 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Prior Authorization and Benefits Chart

2020 prior authorization — durable medical equipment (DME)

We cover all medically necessary durable medical equipment (DME) covered by Original Medicare. Covered DME items include, but are not limited to, diabetic supplies, wheelchairs, walkers, speech-generating devices, oxygen equipment, and CPAP machines.

Items are covered as in-network only if your doctor or other network provider gets approval (also known as "prior authorization") in advance.

Be sure to talk to your doctor before ordering supplies. Your doctor may be able to order for you and provide prior authorization for in-network coverage.

For Personal Choice 65SM PPO, Personal Choice 65SM RX PPO, and Keystone 65 Focus Rx HMO-POS, you can use an in- or out-of-network DME supplier to order your Medicare-covered DME equipment, but you’ll save money by using an in-network supplier. For more information on in- and out-of-network coinsurance amounts, please reference the durable medical equipment section of the Medical Benefits Chart, durable medical equipment section in your Evidence of Coverage (EOC).

For the most recent list of suppliers visit ibxmedicare.com/providerfinder and search "durable medical equipment."

If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special-order it for you.

For diabetic supplies, test strips and monitors must be obtained from preferred vendors/brands Accu-Chek and OneTouch. Test strips and monitors from any other vendor will not be covered. In-network diabetic shoes and inserts, lancets, solutions, insulin pumps, and related supplies from any brand are available to members at no cost.


Appeals for Part C

If you, your doctor, or your representative do not agree with the outcome of the initial organization determination, appeal the decision by requesting a reconsideration. Learn more about the medical appeals process by reviewing your Evidence of Coverage (EOC).

If you are a Keystone 65 HMO member, you can file a standard or expedited medical appeal by using one of the methods below.

  • Call 1-800-645-3965 (TTY/TDD: 711) for expedited appeals only.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652
  • Complete the Request for Reconsideration of Medicare Advantage Denial Online Submission Form
  • Deliver in person to:
    Independence LIVE
    1919 Market Street, 2nd Floor
    Philadelphia, PA 19103
    8 a.m. to 5 p.m. Monday through Friday

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited medical appeal by using one of the methods below.

  • Call 1-888-718-3333 (TTY/TDD: 711) for expedited appeals only.
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652
  • Complete the Request for Reconsideration of Medicare Advantage Denial Online Submission Form
  • Deliver in person to:
    Independence LIVE
    1919 Market Street, 2nd Floor
    Philadelphia, PA 19103
    8 a.m. to 5 p.m. Monday through Friday

If you prefer to file an appeal through CMS, please complete the Medicare Complaint Form.

2021 medical appeals information

For more information on Keystone 65 Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 119 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Medical Appeals

For more information on Keystone 65 Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 182 in your EOC or click on the link below.

Keystone 65 Rx HMO Medical Appeals

For more information on Personal Choice 65SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 126 in your EOC or click on the link below.

Personal Choice 65 Medical-only PPO Medical Appeals

For more information on Personal Choice 65SM Rx PPO Medical Appeals, please reference Chapter 9, Section 4 on page 183 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Medical Appeals

2020 medical appeals information

For more information on Keystone 65 Medical-only HMO Medical Appeals, please reference Chapter 7, Section 4 on page 123 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Medical Appeals

For more information on Keystone 65 Rx HMO Medical Appeals, please reference Chapter 9, Section 4 on page 185 in your EOC or click on the link below.

Keystone 65 Rx HMO Medical Appeals

For more information on Personal Choice 65SM Medical-only PPO Medical Appeals, please reference Chapter 7, Section 4 on page 125 in your EOC or click on the link below.

Personal Choice 65 Medical-only PPO Medical Appeals

For more information on Personal Choice 65SM Rx PPO Medical Appeals, please reference Chapter 9, Section 4 on page 182 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Medical Appeals


Grievances for Part C

You may file a grievance if you have a complaint other than one that involves a coverage determination (see Appeals above). You would file a grievance for any type of problem you might have with us or one of our network providers.

If you are a Keystone 65 HMO member, you can file a standard or expedited grievance. When you file an expedited grievance, we will give you an answer to your grievance within 24 hours. You can file a standard or expedited grievance by using one of the methods below.

  • Call 1-800-645-3965 (TTY/TDD: 711).
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Keystone 65 HMO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652
  • Deliver in person Monday through Friday from 8 a.m. to 5 p.m.:
    Independence LIVE
    1919 Market Street, 2nd Floor
    Philadelphia, PA 19103

If you are a Personal Choice 65SM PPO member, you can file a standard or expedited grievance. When you file an expedited grievance, we will give you an answer to your grievance within 24 hours. You can file a standard or expedited grievance by using one of the methods below.

  • Call 1-888-718-3333 (TTY/TDD: 711).
    Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
  • Fax 1-888-289-3008.
  • Write Personal Choice 65 PPO
    Medicare Members Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652
  • Deliver in person Monday through Friday from 8 a.m. to 5 p.m.,:
    Independence LIVE
    1919 Market Street, 2nd Floor
    Philadelphia, PA 19103

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

2021 medical grievances information

For more information on Keystone 65 Medical-only HMO grievances, please reference Chapter 7, Section 9.3 on page 147 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Grievances

For more information on Keystone 65 Rx HMO grievances, please reference please reference Chapter 9, Section 10.3 on page 222 in your EOC or click on the link below.

Keystone 65 Rx HMO Grievances

For more information on Personal Choice 65SM Medical-only PPO grievances, please reference Chapter 7, Section 9.3 on page 155 in your EOC or click on the link below.

Personal Choice 65 Medical-only PPO Grievances

For more information on Personal Choice 65SM Rx PPO grievances, please reference Chapter 9, Section 10.3 on page 225 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Grievances

2020 medical grievances information

For more information on Keystone 65 Medical-only HMO grievances, please reference Chapter 7, Section 9.3 on page 152 in your EOC or click on the link below.

Keystone 65 Medical-only HMO Grievances

For more information on Keystone 65 Rx HMO grievances, please reference please reference Chapter 9, Section 10.3 on page 225 in your EOC or click on the link below.

Keystone 65 Rx HMO Grievances

For more information on Personal Choice 65SM Medical-only PPO grievances, please reference Chapter 7, Section 9.3 on page 155 in your EOC or click on the link below.

Personal Choice 65 Medical-only PPO Grievances

For more information on Personal Choice 65SM Rx PPO grievances, please reference Chapter 9, Section 10.3 on page 223 in your EOC or click on the link below.

Personal Choice 65 Rx PPO Grievances


Appointment of a representative

If you have someone appealing our decision for you other than your physician, your appeal must include an Appointment of Representative form. View our Medicare documents page for more information.


Out-of-network coverage for Part C

2021 out-of-network coverage for Part C

For more information on Keystone 65 Medical-only HMO out of network coverage for Part C, please reference Chapter 3, Section 2.4 on page 33 or click on the link below.

Keystone 65 Medical-only HMO Out-of-Network Coverage for Part C

For more information on Keystone 65 Rx HMO out of network coverage for Part C, please reference Chapter 3, Section 2.4 on page 45 or click on the link below.

Keystone 65 Rx HMO Out-of-Network Coverage for Part C

For more information on Personal Choice 65SM Medical-only PPO Out of Network Coverage for Part C, please reference Chapter 3, Section 2.3 on page 33 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Out-of-Network Coverage for Part C

For more information on Personal Choice 65SM Rx PPO's out-of-network coverage for Part C, please reference Chapter 3, Section 2.3 on page 43 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Part C Out-of-Network Coverage for Part C

2020 out-of-network coverage for Part C

For more information on Keystone 65 Medical-only HMO out of network coverage for Part C, please reference Chapter 3, Section 2.4 on page 34 or click on the link below.

Keystone 65 Medical-only HMO Out-of-Network Coverage for Part C

For more information on Keystone 65 Rx HMO out of network coverage for Part C, please reference Chapter 3, Section 2.4 on page 45 or click on the link below.

Keystone 65 Rx HMO Out-of-Network Coverage for Part C

For more information on Personal Choice 65SM Medical-only PPO Out of Network Coverage for Part C, please reference Chapter 3, Section 2.3 on page 32 in your EOC or click on the link below.

Personal Choice 65SM Medical-Only PPO Out-of-Network Coverage for Part C

For more information on Personal Choice 65SM Rx PPO's out-of-network coverage for Part C, please reference Chapter 3, Section 2.3 on page 43 in your EOC or click on the link below.

Personal Choice 65SM Rx HMO PPO Part C Out-of-Network Coverage for Part C

For claims and reimbursement

Keystone 65 HMO and Personal Choice 65 PPO:
Claims Receipt Center
PO Box 211184
Eagan, MN 55121


Medicare Advantage medical, claims and technology policies and bulletins

Independence Blue Cross Medicare Advantage benefit programs are comprised of Medical Policy, Technology Assessments and Claims Payment policy bulletins. View our policies. By clicking this link you will be leaving the Independence Blue Cross Medicare website.


Contact information

Members and providers who have questions about the exceptions and appeals processes, would like to inquire about the status of a coverage determination or appeal request please contact the Member Help Team.

To obtain an aggregate number of grievances and appeals filed with Independence Blue Cross, please mail a written request to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652


Dental, hearing, and vision

New for 2021! Dental, hearing, and vision benefits are now built in to all Medicare Advantage plans at NO additional premium. All members now receive access to benefits such as:

  • $0 copay for one routine dental exam/cleaning every six months
  • An annual allowance for comprehensive dental services (varies per plan)
  • $10 copay for one routine eye exam per year
  • One pair of eyeglass frames and lenses or contact lenses up to the covered allowance amount every year
  • $10 copay for one routine hearing exam per year

Learn more about 2021 routine dental, hearing, and vision coverage by reviewing your 2021 Evidence of Coverage (EOC).


IBX Care Card

New for 2021! Medicare Advantage members are eligible to receive an IBX Care Card to purchase over-the-counter (OTC) medicines and health-related items. Your IBX Care Card is prepaid and automatically reloaded each quarter. Your allowance will not carry over to the next quarter if it is not used.

Use your IBX Care Card at participating retail locations including CVS, Walgreens, Walmart, Giant, Rite Aid, Family Dollar, and more. Simply swipe your card at the register — it’s that easy!

Members can also order online or on the phone from the comfort of their home.


Telemedicine visits

New for 2021! Get access to a doctor any time of the day or night, over the phone or by video chat. For non-emergency medical conditions such as colds, flu, rashes, and sinus infections, speak with a doctor at no cost to you. You also have access to a licensed behavioral health professional — all for a low $5 copay. To learn more about this offered benefit, please visit ibxmedicare.com/mdlive or call 1-844-271-8565.


Preventive screenings

Regular checkups and screenings can help spot health conditions before they become problems. Certain preventive screenings, such as breast cancer and colorectal cancer screenings, will have a $0 copay even if they become diagnostic.


Primary care physician

New for 2021! Experience the same great network, without the tiering! Visit any primary care physician (PCP) in your plan’s network and pay the same low copay. Learn more by reviewing your 2021 Evidence of Coverage.


Designated sites

Your physician will tell you where to go for laboratory services. You can locate this designated site information on the front of your ID card.


Evidence of coverage

Looking for additional information or details? For a complete description of benefits, visit our Medicare documents page.

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Website last updated: 9/1/2020