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MediGold 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 not available in Franklin County. 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.

2015

MediGold Value Choice (PPO)

Your Monthly Plan Premium

$43

You will pay No Deductibles

$0

You'll enjoy our Annual Out-of-Pocket Maximum for Added Protection

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

Medical Benefits Included!

Your copay:

Preventive Care

$0 in- and out-of-network

Fitness Center Membership

$0 in-network only

Flu Shots

$0 in- and out-of-network 

Diabetes Supplies

$0 in- and out-of-network 

Office Visit (Primary Care Provider)

$10 in-network
$25 out-of-network

Office Visit (Specialty Care Provider)

$40 in-network
$45 out-of-network

Outpatient Lab Test

$15 in- and out-of-network

Outpatient Diagnostic Test or X-ray

$50 in-network
$65 out-of-network

Outpatient Surgery

$250 in-network
$300 out-of-network

Urgent Care Visit

$40 in- and out-of-network

Emergency Room Visit

$65 Worldwide in- and out-of-network

Inpatient Hospital Care (per stay)

Ask how we further limit your inpatient costs per year.

$270 per day for days 1-5 in-network;

$0 after day 5 in-network

$300 per day for days 1-5 out-of-network;

$0 after day 5 out-of-network

Home Health Care

$0 in- and out-of-network

Prescription Drug (Part D) Benefits Included!

Note: 30, 60 or 90-day supply of drugs may be obtained from participating retail or mail order pharmacies. Extra Savings at mail. Ask about it!

Your copay for a 30-day supply:

 

Tier 1 - Preferred Generic Drugs

$0

Tier 2 - Non-Preferred Generic Drugs

$15

Tier 3 - Preferred Brand Drugs

$45

Tier 4 - Non-Preferred Brand Drugs

$90

Tier 5 - Specialty Drugs

33%

Coverage Gap discounts or benefits?

YES

Dental Benefits

MediGold's 2015 Dental Plan may be separately purchased by new and existing MediGold members. The plan is administered by Delta Dental for a monthly premium of $23. Learn more about MediGold's Dental Plan.

2015 MediGold Value Choice (PPO) Plan Documents

2015 MediGold Central Ohio Summary of Benefits - PPO Plans

2015 MediGold Value Choice (PPO) Evidence of Coverage

Last Updated 9/30/2014 1:54:02 PM