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2022 Medicare Advantage Plan Benefit Details for the MediGold Prime Choice (PPO)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2022 Medicare Advantage Plan Details
Medicare Plan Name:MediGold Prime Choice (PPO)
Location:Wood, Ohio     Click to see other locations
Plan ID:H1846 - 006 - 0     Click to see other plans
Member Services:1-800-240-3851 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the MediGold Prime Choice (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$150 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$4,430
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$5,700
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,388 drugsBrowse the MediGold Prime Choice (PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$10.00$45.00$95.0030%
• Number of Drugs per
  Tier:		4143911009893681
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 004336   PCN: MEDDADV   See BIN/PCNs for all plans
Number of Members enrolled in this plan in Wood, Ohio:less than 10 members
Number of Members enrolled in this plan in (H1846 - 006):25 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 5 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Base
Premium		Part D Supplemental
Premium
$0.00$0.00$0.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D):$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: $150.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $10
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $5 copay per visit
• Primary Out-of-network: $25 copay per visit
• Specialist In-network: $35 copay per visit
• Specialist Out-of-network: $60 copay per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $0-25 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 40% coinsurance (authorization required)
• Lab services In-network: $15 copay (authorization required)
• Lab services Out-of-network: $25 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $180 copay
• Diagnostic radiology services (e.g., MRI) Out-of-network: 40% coinsurance
• Outpatient x-rays In-network: $20 copay
• Outpatient x-rays Out-of-network: 40% coinsurance
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $40 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $375 per day for days 1 through 4
$0 per day for days 5 through 90 (authorization required)
• Out-of-network: 50% per stay (authorization required)
Outpatient hospital coverage
• In-network: $15-275 copay per visit (authorization required)
• Out-of-network: 40% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20
$188 per day for days 21 through 53
$0 per day for days 54 through 100 (authorization required)
• Out-of-network: 50% per stay (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: $0 copay
Ground ambulance
• In-network: $250 copay
• Out-of-network: $250 copay
Rehabilitation services
• Occupational therapy visit In-network: $40 copay
• Occupational therapy visit Out-of-network: $60 copay
• Physical therapy and speech and language therapy visit In-network: $40 copay
• Physical therapy and speech and language therapy visit Out-of-network: $60 copay
Mental health services
• Inpatient hospital - psychiatric In-network: $375 per day for days 1 through 4
$0 per day for days 5 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: 50% per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay
• Outpatient group therapy visit with a psychiatrist Out-of-network: $60 copay
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $60 copay
• Outpatient group therapy visit In-network: $40 copay
• Outpatient group therapy visit Out-of-network: $60 copay
• Outpatient individual therapy visit In-network: $40 copay
• Outpatient individual therapy visit Out-of-network: $60 copay
Opioid treatment program services
• In-network: $40.00 copay
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 30% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 30% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay per item
• Diabetes supplies Out-of-network: 30% coinsurance per item
Dialysis
• 20% coinsurance
Hearing
• Hearing exam In-network: $35 copay
• Hearing exam Out-of-network: $60 copay
• Fitting/evaluation In-network: $0 copay
• Fitting/evaluation Out-of-network: $60-999 copay
• Hearing aids In-network: $699-999 copay (limits apply)
• Hearing aids Out-of-network: $60-999 copay (limits apply)
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Oral exam Out-of-network: $0 copay or 50% coinsurance (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: $0 copay or 50% coinsurance (limits apply)
• Fluoride treatment In-network: $0 copay (limits apply)
• Fluoride treatment Out-of-network: $0 copay or 50% coinsurance (limits apply)
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: $0 copay or 50% coinsurance (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services In-network: $0 copay (limits apply)
• Diagnostic services Out-of-network: $0 copay or 50% coinsurance (limits apply)
• Restorative services In-network: 50% coinsurance (limits apply)
• Restorative services Out-of-network: $0 copay or 50% coinsurance (limits apply)
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions In-network: 50% coinsurance (limits apply)
• Extractions Out-of-network: $0 copay or 50% coinsurance (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply)
• Routine eye exam Out-of-network: $0-50 copay (limits apply)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $0-50 copay (limits apply)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) Out-of-network: $0-50 copay (limits apply)
• Eyeglass frames In-network: $0 copay (limits apply)
• Eyeglass frames Out-of-network: $0-50 copay (limits apply)
• Eyeglass lenses In-network: $0 copay (limits apply)
• Eyeglass lenses Out-of-network: $0-50 copay (limits apply)
• Upgrades: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $35 copay
• Foot exams and treatment Out-of-network: $60 copay
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 30% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 30% coinsurance (authorization required)
Package #1
• Monthly Premium: $22.00
• Deductible: N/A
Package #2
• Monthly Premium: $41.00
• Deductible: N/A




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