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MediGold Southwest OH Essential Care (HMO)

MediGold Southwest OH Essential Care (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 Southwest OH Essential Care (HMO)

Monthly MediGold Premium

$0

Annual Deductible

$0

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

$3,200

Medical Benefits

Your copay:

Doctor Office Visits  (Primary Care)

$10

Doctor Office Visits(Specialty Care)

$45

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

$0-$15

Hospital Admission

$275 per day for days 1-6
$0 for additional days

Ask about our inpatient out-of-pocket maximum protection!

Outpatient Diagnostic Test or X-Ray

$60

Outpatient Surgery

$250

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:

$2 retail/mail

90-day supply:

$6 retail/$0 mail

Tier 1 drugs covered through the gap.

Tier 2 - Non-Preferred Generic Drugs

30-day supply:

$12 retail/mail

90-day supply:

$36 retail/$24 mail

Tier 3 - Preferred Brand Drugs

30-day supply:

$45 retail/mail

90-day supply:

$135 retail/$90 mail

Tier 4 - Non-Preferred Brand Drugs

30-day supply:

$85 retail/mail

90-day supply:

$255 retail/$170 mail

Tier 5 - Specialty Tier Drugs

33%

 

2014 Plan Documents

2014 Southwest Ohio Summary of Benefits

2014 Southwest OH Essential Care (HMO) Evidence of Coverage

Last Updated 1/2/2014 3:44:14 PM