MedicareCommons™

Neutral. Transparent. Retrieval-first.

array(20) { ["plan_name"]=> string(37) "Keystone 65 Select Medical Only (HMO)" ["plan_id"]=> string(9) "H3952-050" ["org_name"]=> string(23) "Independence Blue Cross" ["plan_type"]=> string(3) "HMO" ["region"]=> string(38) "Chester, Delaware, Montgomery Counties" ["moop"]=> string(7) "6000.00" ["deductible"]=> string(12) "Data missing" ["inpatient_hospital"]=> string(88) "$275.00 (days 1–6), $0.00 (days 7–90)
Prior Authorization Required" ["snf"]=> string(91) "$0.00 (days 1–20), $214.00 (days 21–100)
Prior Authorization Required" ["pcp"]=> string(11) "$0.00 Copay" ["specialist"]=> string(12) "$20.00 Copay" ["urgent_care"]=> string(12) "$20.00 Copay" ["er"]=> string(60) "$350.00 Copay
Prior Authorization Required" ["ambulance_ground"]=> string(60) "$225.00 Copay
Prior Authorization Required" ["ambulance_air"]=> string(60) "$225.00 Copay
Prior Authorization Required" ["dental"]=> string(11) "Not Covered" ["vision"]=> string(54) "% - % Coinsurance
$250.00/yr eyewear" ["hearing"]=> string(11) "Not Covered" ["rx"]=> array(2) { ["deductible"]=> string(11) "Not Covered" ["tiers"]=> array(0) { } } ["data_status"]=> string(2) "ok" }
🩺 Doctor’s Office Visits
Service 2026 2025
PrimaryComing soon$0.00 Copay
SpecialistComing soon$20.00 Copay
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
Service 2026 2025
Emergency room careComing soon$350.00 Copay
Prior Authorization Required
Urgent careComing soon$20.00 Copay
Ground ambulanceComing soon$225.00 Copay
Prior Authorization Required
Inpatient hospital careComing soon$275.00 (days 1–6), $0.00 (days 7–90)
Prior Authorization Required
Skilled Nursing FacilityComing soon$0.00 (days 1–20), $214.00 (days 21–100)
Prior Authorization Required
🦶 Foot Care
Service 2026 2025
Foot Exams and Treatments (Medicare-covered)Coming soon20% Coinsurance
Routine Foot CareComing soon0% - 20% Coinsurance
Prior Authorization Required
💆 Chiropractic Care
Service 2026 2025
Medicare-covered chiropracticComing soon20% Coinsurance
Prior Authorization Required
Routine chiropracticComing soon20% Coinsurance
Prior Authorization Required
🧠 Mental Health Services
Service 2026 2025
Outpatient individual therapyComing soon$5.00 Copay
Outpatient group therapyComing soon$5.00 Copay
Inpatient psychiatric hospital careComing soon$275.00 (days 1–6), $0.00 (days 7–90)
Prior Authorization Required
🏋️ Rehabilitation Services
Service 2026 2025
Physical therapy and speech/language therapyComing soon$40.00 Copay
Occupational therapyComing soon$30.00 Copay
Prior Authorization Required
🧰 Medical Equipment and Supplies
Service 2026 2025
Diabetes suppliesComing soon$0.00 Copay
Prior Authorization Required
Durable medical equipmentComing soon$20.00 Copay
6 visits/yr
ProstheticsComing soon$0.00 - $40.00 Copay
🔬 Diagnostics, Lab Services, and Imaging
Service 2026 2025
Diagnostic radiology servicesComing soon$30.00 Copay
Lab servicesComing soon$20.00 Copay
Outpatient x-raysComing soon$0.00 - $40.00 Copay
Diagnostic tests and proceduresComing soon$5.00 Copay
💉 Medicare Part B Drugs
Service 2026 2025
ChemotherapyComing soon0% - 20% Coinsurance
Prior Authorization Required
Other Part B drugs (Medicare-covered)Coming soon$0.00 Copay
Prior Authorization Required

Supplemental Benefits

🦷 Dental Services
Service 2026 2025
Medicare Covered Preventive DentalComing soonNot Covered
Oral examComing soon$0.00 Copay
Dental x-raysComing soon$0.00 Copay
CleaningComing soonNot Covered
PeriodonticsComing soon20% Coinsurance
EndodonticsComing soon20% Coinsurance
Restorative ServicesComing soon40% Coinsurance
Dental MaximumComing soonNot Covered
👂 Hearing Aids and Services
Service 2026 2025
Fitting/evaluationComing soon$0.00 Copay
Hearing aidsComing soon$0.00 Copay
Hearing examComing soonNot Covered
Hearing MaximumComing soonNot Covered
👓 Vision Services
Service 2026 2025
Medicare-covered eye examComing soonNot Covered
Routine eye examComing soon% - % Coinsurance
Eyewear benefitsComing soon% - % Coinsurance
Vision Eyewear MaximumComing soon$250.00/yr eyewear
{listing_template_3} {listing_template_4}

Part D Plan Premium

The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.

{name} Prescription Drug Plan Premium Details
Basic Part D Premium: ${part_d_basic_premium}
Supplemental Part D Premium: ${part_d_supplemental_premium}
Total Part D Premium: ${part_d_total_premium}
Low-Income Premium Subsidy: ${part_d_lips_amount}
Low-Income Premium Subsidy Paid by CMS: ${part_d_lips_cms_pays}
Low-Income Subsidy Premium: ${part_d_lis_premium}

For more details, visit the Social Security Extra Help program.

Prescription Drug Plan Deductible

This plan has a ${deductible} annual Part D deductible. You'll pay this deductible at the pharmacy before {carrier} starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, {name} may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

{name} Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
*Deductible does not apply.