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MediGold 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 Evidence of Coverage and Summary of Benefits documents. They provide information about this plan option in more detail.

2014

MediGold Network Choice (PPO)

Monthly MediGold Premium

$143

Annual Deductible

$0

Annual Out-of-Pocket Maximum Protection
The most you could spend on medical care in 2014

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

Medical Benefits

Your copay:

Doctor Office Visits  (Primary Care)

$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 & 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

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

Outpatient Diagnostic Test or X-Ray

$40 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:

Tier 1 - Preferred Generic Drugs

30-day supply:

$0 retail/mail

90-day supply:

$0 retail/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 2 drugs covered through the gap.

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 MediGold Network Choice (PPO) Plan Documents

2014 MediGold Central Ohio Summary of Benefits - PPO Plans

2014 MediGold Network Choice (PPO) Evidence of Coverage

Last Updated 1/2/2014 3:54:02 PM