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:
- Wellness programs.
- Transportation to the doctor.
- Hearing, dental, and vision benefits.
- 24-hour 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:
- 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.
- A Keystone First VIP Choice Evidence of Coverage (EOC) (PDF).
- 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.|
$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:
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 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 every three years for hearing aids for both ears combined.
$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 $200 every two years for contact lenses and eyeglasses (frames and lenses).
$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.
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.