Value Choice (PPO)

MediGold Value Choice (PPO) is a Medicare Advantage Preferred Provider Organization (PPO), which includes Part D prescription drug coverage. This plan is only available in Clark, Greene, Knox, Montgomery and Richland Counties, Ohio. With MediGold Value Choice (PPO), you have 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.

2012	MediGold Value Choice (PPO)
Monthly MediGold Premium	$28
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)	$20 in-network & out-of-network
Doctor Office Visits(Specialty Care)	$45 in-network & out-of-network
Lab Tests, Home Health Care, and Medicare-covered Preventive Services	$0 in-network & out-of-network
Hospital Admission	$225 per day for days 1-7; $0 for additional days in-network & out-of-network
Outpatient Diagnostic Test or X-Ray	$45 in-network & out-of-network
Outpatient Surgery	$250 in-network & 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

Value Choice (PPO) Plan Documents

2012 MediGold Value Choice (PPO) Summary of Benefits

2012 MediGold Value Choice (PPO) Evidence of Coverage

2012 MediGold Value Choice (PPO) Annual Notice of Changes

Last Updated 1/3/2012 9:59:20 AM