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2010 Option 1 – MediGold Essential Care (HMO)
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2010 Option 2 – MediGold Classic Preferred (HMO)
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2010 Option 3 – MediGold Medical Only (HMO)
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2010 Option 4 – MediGold Network Choice (PPO)
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Service Area
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Clark, Delaware, Fairfield, Fayette, Franklin, Greene, Knox, Licking, Madison, Montgomery, Pickaway, Richland, Ross and Union
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Monthly MediGold Premium
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$72
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$99
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$124
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$147
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Primary Care Physician (PCP)
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$15 copay
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$10 copay
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$0 copay
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In-network
$0 copay
Out-of-network
$15 copay
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Specialty Care Physician (SCP)
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$35 copay
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$25 copay
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$0 copay
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In-network
$0 copay
Out-of-network
$35 copay
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Inpatient Hospital Admissions
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$110 copay per day for days 1-16 (per admission)
$0 copay for additional hospital days
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$0 copay per admission
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$200 copay per admission
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In-network
$200 copay per admission
Out-of-network non-emergency admissions
$600 copay per admission
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Outpatient Services
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$35 copay for tests
$250 copay for surgery
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$15 copay for tests
$100 copay for surgery
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$0 copay for tests
$0 copay for surgery
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In-network
$0 copay for tests
$100 copay for surgery
Out-of-network
$35 copay for tests
$250 copay for surgery
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Emergency Care
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$50 copay
(Waived if admitted within 48 hours for same condition.)
Covered Worldwide
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$50 copay
(Waived if admitted within 48 hours for same condition.)
Covered Worldwide
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$0 copay
Covered Worldwide
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In and Out-of-network
$0 each visit
Covered Worldwide
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Urgent Care
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$35 copay
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$25 copay
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$0 copay
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In and Out-of-network
$0 copay
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Diabetic Supplies
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$0 copay
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$0 copay
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$0 copay
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In-network
$0 copay
Out-of-network
50% coinsurance
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Lab Services
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$0 copay
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$0 copay
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$0 copay
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In-network
$0 copay
Out-of-network
$0 copay
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Part D Prescription Drug Copays
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No Deductible.
Listed copays are for a 30-day supply.
$10 Value Generic
$15 Generic
$40 Preferred Brand
$75 Non Preferred Brand
25% Specialty Brand coinsurance
All drugs are subject to the coverage gap.
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No Deductible.
Listed copays are for a 30-day supply.
$5 Value Generic
$10 Generic
$25 Preferred Brand
$40 Non Preferred Brand
25% Specialty Brand coinsurance
Generics are covered through the gap.
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This plan option does not include Part D Prescription Drug Coverage
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No Deductible.
Listed copays are for a 30-day supply.
$5 Value Generic
$10 Generic
$25 Preferred Brand
$40 Non Preferred Brand
25% Specialty Brand coinsurance
Generics are covered through the gap.
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Dental
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For more information on this Optional Supplemental Dental Benefit, click here.
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Additional Membership Perks
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Click here to learn more.
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