Network Choice (PPO)

MediGold Network Choice (PPO) is a Medicare Advantage Preferred Provider Organization (PPO), which includes Part D prescription drug coverage. This plan offers the flexibility to use both in-network and out-of-network providers, although you may pay more for out-of-network care, except for urgent or emergent care or out-of-area renal dialysis. 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 Network Choice (PPO)
Monthly MediGold Premium	$149
Annual Deductible	$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:
Doctor Office Visits (Primary Care)	$15 in-network $20 out-of-network
Doctor Office Visits(Specialty Care)	$30 in-network $40 out-of-network
Lab Tests, Home Health Care, and Medicare-covered Preventive Services	$0 in-network $0-60 out-of-network
Hospital Admission	$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
Outpatient Diagnostic Test or X-Ray	$45 in-network $60 out-of-network
Outpatient Surgery	$250 in-network $300 out-of-network
Diabetic Supplies	0% in-network & out-of-network
Emergency Room Visit	$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:
Tier 1 - Preferred Generic Drugs	$4 retail $0 mail
Tier 2 - Non-Preferred Generic Drugs	$12 retail/mail
Tier 3 - Preferred Brand Drugs	$45 retail/mail
Tier 4 - Non-Preferred Brand Drugs	$75 retail/mail
Tier 5 - Specialty Tier Drugs	33% retail/mail

Network Choice (PPO) Plan Documents

2012 MediGold Network Chocie (PPO) Summary of Benefits

2012 MediGold Network Choice (PPO) Evidence of Coverage

2012 MediGold Network Choice (PPO) Annual Notice of Changes

Last Updated 1/3/2012 9:57:27 AM