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 Annual Notice of Changes, Evidence of Coverage and Summary of Benefits documents. They provide information about this plan option in more detail.

2012	MediGold Classic Preferred (HMO)
Monthly MediGold Premium	$97
Annual Deductible	$0
Annual Out-of-Pocket Maximum Protection The most you could spend on medical care in 2012	$3,400
Medical Benefits	Your copay:
Doctor Office Visits (Primary Care)	$10
Doctor Office Visits(Specialty Care)	$25
Lab Tests, Home Health Care, and Medicare-covered Preventive Services	$0
Hospital Admission	$0
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 and have some benefits or discounts through the Coverage Gap.	Your copay for a 30-day supply:
Tier 1 - Preferred Generic Drugs	$4 retail $0 mail
Tier 2 - Non-Preferred Generic Drugs	$10 retail/mail
Tier 3 - Preferred Brand Drugs	$38 retail/mail
Tier 4 - Non-Preferred Brand Drugs	$50 retail/mail
Tier 5 - Specialty Tier Drugs	33% retail/mail

Classic Preferred (HMO) Plan Documents

2012 MediGold Classic Preferred (HMO) Summary of Benefits

2012 MediGold Classic Preferred (HMO) Evidence of Coverage

2012 MediGold Classic Preferred (HMO) Annual Notice of Changes

Last Updated 1/3/2012 9:54:37 AM