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For your convenience, below are important forms and documents to help you easily manage your health coverage.

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Medical benefits (Part C)

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Prescription drugs (Part D)

The following information can help you get the most from your prescription drug (Part D) coverage.

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Y0041_HM_108885_2023
Website last updated: 8/22/2022

*Please note that on weekends and holidays from April 1 to September 30, your call may be sent to voicemail.

¹2024 Medicare Advantage Enrollment Numbers, ibxmedicare.com/popular24

²2024 PA-5 Provider Network Counts, ibxmedicare.com/providers24

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 PPO, HMO-POS, and HMO Medicare Advantage plans with a Medicare contract. Enrollment in Independence Blue Cross PPO, HMO-POS, and HMO Medicare Advantage plans depends on contract renewal.

Independence Blue Cross offers products through its subsidiaries Independence Assurance Company, Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance – independent licensees of Blue Cross and Blue Shield Association.

Medicare beneficiaries may also enroll in Keystone 65 HMO, Keystone 65 HMO-POS, Personal Choice 65^SM PPO, or Select Option^® PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

Keystone 65 HMO and Personal Choice 65^SM 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.

2025 dental benefits are offered by QCC Insurance Company or Keystone Health Plan East.

Vision benefits are offered by QCC Insurance Company or Keystone Health Plan East and administered by Davis Vision, an independent company.

An affiliate of Independence Blue Cross has a financial interest in Visionworks, 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 transportation benefit is provided by Roundtrip, an independent company.

Strive Health, LLC is an independent company that administers kidney care management to select members of Independence Blue Cross Medicare Advantage plans.

One Pass is a voluntary program offered by an independent company. The One Pass program varies by plan/area. Information provided is not medical advice. Consult a health care professional before beginning any exercise program.

TruHearing^® is a registered trademark of TruHearing, Inc., an independent company.

Teladoc Health and the practitioners accessible through Teladoc Health are independent companies and contractors not affiliated with Keystone 65 HMO/POS and Personal Choice 65 PPO. Please consult a physician for personalized medical advice. Always seek the advice of a physician or other qualified health care provider with any questions regarding a medical condition.

Independence Blue Cross has contracted with ComplexCare Solutions, an independent company and affiliate of Inovalon, Inc., to perform personal health visits for Independence Blue Cross members. ComplexCare Solutions is a business associate (as defined by the Health Insurance Portability and Accountability Act (HIPAA)) of Independence Blue Cross and will maintain the confidentiality of all Protected Health Information (PHI). 03/2023.

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.

The DVH and Medical + DVH flex allowances are preloaded on the IBX Care Card and are a separate wallet from the OTC benefit provided on the same card. Any unused balance will not roll over to the next year. Members should retain the card through the expiration date. When using your IBX Care Card, if the member exceeds the benefit amount, alternative payment will be required for the remaining balance due. Members should ask the provider if they accept split payment methods prior to receiving services.

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 your physician before ordering these items. Items include, but are not limited to, vitamins and minerals, home monitoring and testing, and weight loss items.

OTC Network^®, OTC Network^® app, and Convey Health Solutions are provided by InComm Payments^TM, an independent company. All trademarks/service marks are the property of their respective owners.

Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2024, and from time to time during the year.

The grocery benefit is provided by FareRx, an independent company. For select plans, the grocery benefit mentioned is part of a special supplemental program for the chronically ill. Members must be diagnosed with diabetes, depression or depressive disorders, disabling mental health conditions, chronic heart failure, hypertension, or other eligible conditions to qualify. Eligible conditions vary by benefit and plan. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. Contact us to confirm your eligibility for this benefit.

For select plans, the grocery benefit mentioned is part of a special supplemental program for the chronically ill. Members must be diagnosed with diabetes, depression or depressive disorders, disabling mental health conditions, chronic heart failure, hypertension, or other eligible conditions to qualify. Eligible conditions vary by benefit and plan. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. Contact us to confirm your eligibility for this benefit.

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.