2013

MediGold Network Choice (PPO)

Monthly MediGold Premium

$145

Annual Deductible

$0

Annual Out-of-Pocket Maximum Protection
The most you could spend on medical care in 2013

New! $3,200 in-network
New! $5,000 combined in-network & out-of-network

Medical Benefits

Your copay:

Doctor Office Visits  (Primary Care)

New! $0 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

$225 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!

Your copay for a
30-day supply:

Tier 1 - Preferred Generic Drugs

$0

Tier 1 drugs covered through the gap.

Tier 2 - Non-Preferred Generic Drugs

$12

Tier 2 drugs covered through the gap.

Tier 3 - Preferred Brand Drugs

$45

Tier 4 - Non-Preferred Brand Drugs

$75

Tier 5 - Specialty Tier Drugs

33%