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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:

  • Preventive services to help you stay healthy.
  • Wellness education including smoking cessation and a nurse hotline.
  • Great service and personal attention.

Questions? Call 1-800-450-1166 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.

Below is a brief summary of key benefits.

You may also view:

The EOC tells you how to get Medicare 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.

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.
Specialist visits

$0 copay for each Medicare-covered specialist visit.

No referral required.

Preventive and comprehensive dental

$0 copay for Medicare-covered dental benefits.

Preventive dental services:

  • Cleaning (for up to one every six months).
  • Dental X-ray(s) (for up to one every year).
  • Fluoride treatment (for up to one every six months).
  • Oral exam (for up to one every six months).

The comprehensive dental benefit covers minor restorations (fillings), simple extractions, dentures, and denture repair up to $1,000 every two years. Periodontics, endodontics, oral maxillofacial surgery, and other prosthodontics are not covered services.

Hearing exams and aids

$0 copay for Medicare-covered diagnostic hearing exams.

$0 copay for up to one supplemental routine hearing exam every year.

$0 copay for one fitting evaluation for a hearing aid every three years.

$0 copay for up to one hearing aid every three years.

$1,000 allowance for hearing aids every three years.

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 two years.
  • Up to one pair of contact lenses every two years.

We pay up to $200 every two years for contact lenses and eyeglasses (frames and lenses).

Transportation

$0 for up to 30 one-way trips to plan-approved locations every year. May consist of car, shuttle, or van service depending on appropriateness for situation.

Authorization and scheduling rules apply.

Over-the-counter (OTC) items You may spend up to $70 per quarter for items from our OTC catalog. 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.

$0 copay for Medicare-covered partial hospitalization program services.

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