Please submit this form to make a request for Medicare prescription drug coverage determination. Coverage determination can also be requested by calling 1-888-678-7015 (TTY/TDD: 711).
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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.
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To ensure your privacy, all information will be sent via a secure connection. Independence Blue Cross will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law. Please see our Notice of Privacy Practices for more information.
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 or the Request for Redetermination of Medicare Prescription Drug Denial.
For additional information from the Centers for Medicare and Medicaid Services (CMS) visit http://www.medicare.gov. 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 ‐ independent licensees of the Blue Cross and Blue Shield Association.
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
Keystone 65 HMO and Personal Choice 65SM PPO: For accommodation of persons with special needs at meetings call toll-free 1-877-393-6733 (711 for the speech- and hearing-impaired).
Every year, Medicare evaluates plans based on a 5-Star rating system.
MedigapFreedom: 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.
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.
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.
Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross ‐ independent licensees of the Blue Cross and Blue Shield Association.
Not connected with or endorsed by the U.S. Government or the federal Medicare program.
The SilverSneakers®fitness program is provided by Tivity Health, Inc., an independent company. © 2020. 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.
The Independence Blue Cross OTC benefit is underwritten by Keystone Health Plan East/QCC and is administered by Convey Health Solutions, Inc., an independent company.
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.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.
Website last updated: 2/10/2020 Y0041_HM_20_76211e