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MediGold Classic Preferred (HMO)

MediGold Classic Preferred (HMO) is a Medicare Advantage Health Maintenance Organization (HMO), which includes Part D prescription drug coverage. The chart below provides a summary of the benefits available with this plan. You may also find it helpful to review the Evidence of Coverage and Summary of Benefits documents. They provide information about this plan option in more detail.

 

2014

MediGold Classic Preferred (HMO)

Monthly MediGold Premium

$99

Annual Deductible

$0

Annual Out-of-Pocket Maximum Protection
The most you could spend on medical care in 2014

$3,200

Medical Benefits

Your copay:

Doctor Office Visits  (Primary Care)

$0

Doctor Office Visits(Specialty Care)

$30

Lab Tests, Home Health Care, and Medicare-covered Preventive Services

$0

Hospital Admission

$0 per stay

Outpatient Diagnostic Test or X-Ray

$15

Outpatient Surgery

$125

Diabetic Supplies

0%

Emergency Room Visit

$65

Prescription Drug Benefits (Part D)

You pay no deductibles!

Your copay:

Tier 1 - Preferred Generic Drugs

30-day supply:

$0 retail/mail

90-day supply:

$0 retail/mail

Tier 1 drugs covered through the gap.

Tier 2 - Non-Preferred Generic Drugs

30-day supply:

$10 retail/mail

90-day supply:

$30 retail/$20 mail

Tier 2 drugs covered through the gap.

Tier 3 - Preferred Brand Drugs

30-day supply:

$38 retail/mail

90-day supply:

$114 retail/$76 mail

Tier 4 - Non-Preferred Brand Drugs

30-day supply:

$50 retail/mail

90-day supply:

$150 retail/$100 mail

Tier 5 - Specialty Tier Drugs

33%

2014 MediGold Classic Preferred (HMO) Plan Documents

2014 MediGold Central Ohio Summary of Benefits - HMO Plans

2014 MediGold Classic Preferred (HMO) Evidence of Coverage

Last Updated 1/2/2014 3:51:39 PM