2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Keystone 65 Preferred Rx (HMO) | ||||
Location: | Bucks, Pennsylvania Click to see other locations | ||||
Plan ID: | H3952 - 020 - 0 Click to see other plans | ||||
Member Services: | 1-800-645-3965 TTY users 1-888-857-4816 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Keystone 65 Preferred Rx (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $143.20 (see Plan Premium Details below) | ||||
Annual Deductible: | $100 | ||||
Annual Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Gap Coverage? | Many Generics | ||||
Total Number of Formulary Drugs: | 4,570 drugs | Browse the Keystone 65 Preferred Rx (HMO) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $5.00 | $30.00 | $80.00 | 25% | |
• Number of Drugs per Tier: | 1795 | 556 | 1987 | 232 | |
Plan's Pharmacy Search: | http://www.site65.com/pgs_section_1-6_pages/03_rx_network_ind.html | ||||
Number of Members enrolled in this plan in (H3952 - 020): | 21,511 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — |