Keystone 65 Liberty Medical Only (HMO)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: Yes, contact plan for further details

Comprehensive Dental

• Adjunctive General Services
  • In-Network: No Coins – 0.00 Copay (Limits Apply)
• Endodontics
  • In-Network: 20 Coins – No Co pay
• Implant Services
  • In-Network: 40 Coins – No Co pay
• Oral and Maxillofacial Surgery
  • In-Network: 20-40 Coins – No Co pay (Limits Apply)
• Periodontics
  • In-Network: 20 Coins – No Co pay
• Prosthodontics, fixed
  • In-Network: 40 Coins – No Co pay
• Prosthodontics, removable
  • In-Network: 40 Coins – No Co pay
• Restorative Services
  • In-Network: 20 Coins – No Co pay

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – 0.00 Copay
• Fluoride Treatment
  • In-Network: No Coins – 0.00 Copay
• Oral Exams
  • In-Network: No Coins – 0.00 Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • $0-275 copay (Authorization Required)
• Diagnostic tests and procedures
  • $0 copay (Authorization Required)
• Lab services
  • $0 copay (Authorization Required)
• Outpatient x-rays
  • $45 copay (Authorization Required)

Doctor visits

• Primary
  • $0 copay
• Specialist
  • $40 copay per visit

Emergency care/Urgent care

• Urgent care
  • $15-45 copay per visit (always covered)
• Emergency
  • $110 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • $25 copay
• Routine foot care
  • $25 copay (Limits Apply)

Ground ambulance

• • $260 copay

Health plan deductible

• • $0

Hearing

• Fitting/evaluation
  • $0 copay
• Medicare-Covered Hearing Exam
  • $40 copay
• Hearing aids OTC
  • Not covered
• Hearing aids
  • $699-999 copay (Limits Apply)

Inpatient hospital coverage

• • $285 per day for days 1 through 7
    $0 per day for days 8 through 90
    $0 per day for days 91 and beyond (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $9,350 In-network

Medical equipment/supplies

• Durable medical equipment (e.g., wheelchairs, oxygen)
  • 20% coinsurance per item (Authorization Required)
• Prosthetics (e.g., braces, artificial limbs)
  • 20% coinsurance per item (Authorization Required)
• Diabetes supplies
  • 0-20% coinsurance per item (Authorization Required)

Medicare Part B drugs

• Chemotherapy
  • 0-20% coinsurance (Authorization Required)
• Other Part B drugs
  • 0-20% coinsurance (Authorization Required)

Mental health services

• Inpatient hospital – psychiatric
  • $285 per day for days 1 through 7
    $0 per day for days 8 through 90 (Authorization Required)
• Outpatient group therapy visit with a psychiatrist
  • $20 copay
• Outpatient individual therapy visit with a psychiatrist
  • $30 copay
• Outpatient group therapy visit
  • $20 copay (Authorization Required)
• Outpatient individual therapy visit
  • $30 copay (Authorization Required)

Optional supplemental benefits

• • No

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • 20% coinsurance per visit (Authorization Required)

Preventive care

• • $0 copay (Authorization Required)

Rehabilitation services

• Occupational therapy visit
  • $35 copay
• Physical therapy and speech and language therapy visit
  • $35 copay

Skilled Nursing Facility

• • $0 per day for days 1 through 20
    $214 per day for days 21 through 100 (Authorization Required)

Transportation

• • Not covered

Vision

• Upgrades
  • Not covered
• Eyeglass frames
  • Not covered
• Eyeglass lenses
  • Not covered
• Eyeglasses (frames and lenses)
  • $0 copay (Limits Apply)
• Other
  • Not covered
• Contact lenses
  • $0 copay (Limits Apply)
• Routine eye exam
  • $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

• • Covered