2012

MediGold Essential Care (HMO)

MediGold Classic Preferred (HMO)

MediGold Medical Only (HMO)

MediGold Network Choice (PPO)

MediGold Value Choice (PPO)*

Monthly MediGold Premium

$0

$97

$43

$149

$28

Annual Deductible

$0

$0

$0

$0

$0

Annual Out-of-Pocket Maximum Protection
The most you could spend on medical care in 2012

$3,400 in-network
$5,100 combined in-network & out-of-network

Medical Benefits

Your copay:

Your copay:

Your copay:

Your copay:

Your copay:

Doctor Office Visits  (Primary Care)

$10

$10

$10

$15 in-network
$20 out-of-network

$20 in-network
& out-of-network

Doctor Office Visits(Specialty Care)

$45

$25

$25

$30 in-network
$40 out-of-network

$45 in-network
& out-of-network

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

$0

$0

$0

$0 in-network
$0-60 out-of-network

$0 in-network
& out-of-network

Hospital Admission

$225 per day for days 1-7
$0 for additional days

$0

$50 per day for days 1-7
$0 for additional days

$200 per day for days 1-7; $0 for additional days in-network

$250 per day for days 1-7; $0 for additional days out-of-network

$225 per day for days 1-7; $0 for additional days in-network & out-of-network

Outpatient Diagnostic Test or X-Ray

$55

$15

$35

$45 in-network
$60 out-of-network

$45 in-network
& out-of-network

Outpatient Surgery

$250

$125

$125

$250 in-network
$300 out-of-network

$250 in-network
& out-of-network

Diabetic Supplies

0%

0%

0%

0% in-network
& out-of-network

0% in-network
& out-of-network

Emergency Room Visit

$65

$65

$65

$65 in-network
& out-of-network

$65 in-network
& out-of-network

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:

Your copay for a
30-day supply:

Part D not included

Your copay for a
30-day supply:

Your copay for a
30-day supply:

Tier 1 - Preferred Generic Drugs

$4 retail

$0 mail

$4 retail

$0 mail

$4 retail

$0 mail

$4 retail

$0 mail

Tier 2 - Non-Preferred Generic Drugs

$12 retail/mail

$10 retail/mail

$12 retail/mail

$12 retail/mail

Tier 3 - Preferred Brand Drugs

$45 retail/mail

$38 retail/mail

$45 retail/mail

$45 retail/mail

Tier 4 - Non-Preferred Brand Drugs

$75 retail/mail

$50 retail/mail

$75 retail/mail

$75 retail/mail

Tier 5 - Specialty Tier Drugs

33% retail/mail

33% retail/mail

33% retail/mail

33% retail/mail

Dental Benefits

MediGold's 2012 Dental Plan may be separately purchased by new and existing MediGold members. The plan is administered by Delta Dental for a monthly premium of $20. Learn more about MediGold's Dental Plan.