Y0041_HM_19_68654 Accepted 10/1/2018
Independence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Independence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. View our documentation for more information and to request language assistance services.
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
Request for Redetermination of Medicare Prescription Drug Denial
For additional information from the Centers for Medicare and Medicaid Services (CMS) visit
. 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 Medicare Advantage plans with a Medicare contract. Enrollment in Independence Medicare Advantage plans depends on contract renewal.
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
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.
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.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits, formulary, premium and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Medicare beneficiaries may also enroll in Keystone 65 HMO, Personal Choice 65SM PPO, or Select Option® PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov
Every year, Medicare evaluates plans based on a 5-Star rating system.
MedigapSecurity plans are offered through Independence Blue Cross and Highmark Blue Shield, independent licensees of the Blue Cross and Blue Shield Association. MedigapSecurity is not connected with or endorsed by the U.S. government or the federal Medicare program. 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.
The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. ©2018. All rights reserved. TruHearing® is a registered trademark of TruHearing, Inc., an independent company. FutureScripts® is an independent company that provides pharmacy benefit management services.
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.
By voluntarily giving Independence Blue Cross my phone number (including my mobile number) and/or e-mail address, I authorize Independence Blue Cross and its subsidiaries (collectively “Independence”) to send me information/data about Independence, including, but not limited to, information about my account and other insurance products and services. Independence may contact me via e-mail, automated text, and/or phone call. For text, message and data rates may apply. Not required to purchase goods and services from Independence Blue Cross. Text STOP to stop and HELP for help. Terms and conditions at www.myhelpsite.net/ibx