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
- 24/7 Nurse Call Line
- Great service and personal attention
Questions? Call 1-855-241-3648 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31.
Below is a brief summary of key benefits.
You may also view:
- Pre-Enrollment Checklist (PDF)
- Summary of Benefits (PDF)
- Over-the-Counter Benefit Product Catalog (OTC) (PDF)
- Spanish Over-the-Counter Benefit Product Catalog (OTC) (PDF)
- Review information about your over-the-counter benefits online by visiting &more Health. You can also call 1-855-AND-MORE (1-855-263-6673; TTY 711), Monday – Friday from 8 a.m. to 8 p.m. local time.
- Annual Notice of Changes (ANOC) (PDF)
- The ANOC tells you about all plan changes in the next year.
- Evidence of Coverage (EOC) (PDF)
- The EOC tells you how to get Medicare-covered 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 following benefits:
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
There is no cost to you for preventive dental benefits every year, which include the following services:
- One routine visit per year
- Oral exams - One every six months
- Cleaning - One every six months
- Fluoride treatment - One every six months
- Dental X-rays - One dental X-ray visit every five years (frequency varies by service)
- One full mouth radiograph and one panoramic radiograph every five years
- Up to six bitewing or periapical radiographs every year
The combined total comprehensive dental benefits cannot exceed $4,250 every year. The comprehensive dental benefits include the following services up to a $4,250 combined limit every year:
- Minor restorations (fillings)
- Extractions - One per tooth per lifetime
- Dentures - One per arch every five years
- Denture repair and reline - One per year
- Oral surgery
- Periodontics
- Endodontics
- Crowns, one every five years, per tooth. No more than four per calendar year, with no more than two crowns per arch per year.
- Mini-implants (lower arch only) and implant-supported denture (lower arch only), one every five years.
Limits:
Prior authorization is required for dentures, periodontics, endodontics, crowns, mini-implants, implant supported dentures, and extractions before services are rendered.
Fixed bridges and all other dental implants, except for mini-implants, are not covered services.
Hearing exams and aids
Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.
- $0 for up to one routine hearing exam every year
Hearing aid benefit includes:
- $0 copay for Select-level technologies every 3 years
- Up to two [2] hearings aids (1 aid per ear) every 3 years for Select hearing aid technology
- Levels through NationsHearing at no cost
All hearing aids offered through NationsHearing include:
- 60-day evaluation period with a 100% money-back guarantee (no restocking fees)
- 1 Hearing aid fitting per hearing aid
- 3 follow-up appointments within one year of the fitting date
- 3-year supply of batteries (for nonrechargeable hearing aids, up to 60 cells per ear, per year)
- 3-year comprehensive manufacturer's warranty, including one time replacement for lost or damaged hearing aids
- Earmold(s) (first set, when needed)
- Unlimited ongoing member support via NationsHearing
Vision services
Covered services include:
- $0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye.
- $0 copay for up to one routine vision exam every year.
- Up to $500 every year towards eyeglasses or contact lenses.
Transportation
Twelve one-way trips to plan-approved locations every year (e.g., doctor's office, pharmacy, and hospital). May consist of a car, shuttle, or van service, depending on appropriateness for the situation and the member's needs. Rides must be scheduled at least one business day in advance except in special circumstances. Transportation is authorized for plan-approved locations only (e.g., doctor's office, pharmacy, and hospital).
Limit of 50 miles per one-way trip
Over-the-counter (OTC)
$100 per month allowance combined with SSBCI eligible items using the flex spending debit card on eligible OTC items such as vitamins, pain relievers, cold remedies, and more.
If a member qualifies, the OTC credit will be combined with the SSBCI credit.
- Shop through the OTC catalog (PDF), Spanish OTC catalog (PDF) or at participating retail stores
- No limit on the number of items or orders
- Any unused funds will expire at the end of the month or upon disenrollment from the plan.
- Naloxone is covered as a Part C OTC benefit. The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
Home health care
$0 copay for Medicare-covered home health visits.
Prior authorization is required for home health care services.
Outpatient mental health care
$0 copay for each Medicare-covered individual therapy visit.
$0 copay for each Medicare-covered group therapy visit.
Important message about what you pay for vaccines
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
Special Supplemental Benefits for the Chronically Ill (SSBCI):
Members who qualify will receive a $100 monthly credit on a plan-issued debit card to help with everyday living expenses. This credit can be used for:
- Over the Counter (OTC) eligible items
- Healthy foods
- General supports for living (e.g., rent, mortgage, utilities)
- Pest control
- Non-medical transportation
If a member qualifies, the OTC credit will be combined with the SSBCI credit. Any unused funds will expire at the end of the month or upon disenrollment from the plan.
In order to qualify for SSBCI, members must have at least one of the following chronic health conditions: Cardiovascular disorders; chronic and disabling mental health conditions; chronic gastrointestinal disease (limited to end stage liver disease); chronic lung disorders (limited to chronic obstructive pulmonary disorder); congestive heart failure; connective tissue disease; dementia; diabetes mellitus; overweight, obesity, and metabolic syndrome; and stroke. In addition, the condition must be life threatening or greatly limit overall health or function of the member; the member must be at high risk of hospitalization or other adverse health outcomes; and the member must require intensive care coordination. The plan will review objective criteria to determine a member’s eligibility. For more information or to check eligibility, members should contact the plan.
Unused amounts expire at the end of each month or upon disenrollment from the plan.
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