Mount Carmel MediGold Premier (HMO)
Available to residents of Gallia County, OH for 2026. Contract H3668, plan 018, segment 1.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Gallia County
- Plan website
- Browse the Mount Carmel MediGold Premier (HMO) formulary
Plan details
| Monthly premium (Part C + D) | $102.00 |
|---|---|
| — medical (Part C) part | $88.80 |
| — drug (Part D) part | $13.20? |
| Monthly premium with full Extra Help (LIS) | $88.80?drug (Part D) part $0.00; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $3,900.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H3668-018-1 |
| Offered by | MediGold |
| Parent organization | Trinity Health Corporation |
| Formulary drugs | 3,507 |
| Formulary exception tier | 5? |
| Pharmacy search | www.thpmedicare.org/mount-carmel/find-a-provider |
| Member services | (800)964-4525TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H3668 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay |
| Other health care professional | $0–$30 copay |
| Additional telehealth services | $0–$30 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $20 copay(authorization required) |
| Lab services | $0 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $85 copay |
| Therapeutic radiology | 20% coinsurance |
| Outpatient x-rays | $20 copay |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $40 copay |
| Worldwide emergency coverage | $130 copay |
| Worldwide urgent care | $130 copay |
| Worldwide emergency transportation | $200–$250 copay |
| Hospital care | |
| Inpatient hospital stay | $190 per day for days 1–4; $0 per day for days 5–90(authorization required) |
| Outpatient hospital services | $0–$175 copay |
| Outpatient observation | $180 copay |
| Ambulatory surgical center | $175 copay |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–60; $0 per day for days 61–100 |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $35 copay |
| Physical therapy and speech-language therapy | $35 copay |
| Cardiac rehabilitation | $30 copay |
| Pulmonary rehabilitation | $15 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $190 per day for days 1–4; $0 per day for days 5–90(authorization required) |
| Outpatient mental health, individual session | $25 copay |
| Outpatient mental health, group session | $25 copay |
| Psychiatrist, individual session | $25 copay |
| Psychiatrist, group session | $25 copay |
| Partial hospitalization | $45 copay |
| Intensive outpatient program | $45 copay |
| Outpatient substance use, individual session | $25 copay |
| Outpatient substance use, group session | $25 copay |
| Opioid treatment program | $25 copay |
| Ambulance and transportation | |
| Ground ambulance | $200 copay(authorization required) |
| Air ambulance | $250 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $20 copay(authorization required) |
| Routine chiropractic care | Not covered |
| Acupuncture | $20 copay(authorization required, limits apply) |
| Foot exams and treatment (Medicare-covered) | $30 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $30 copay |
| Preventive dental plan limit | $1,000 plan limit every year |
| Restorative services (fillings, crowns) | 50% coinsurance(limits apply) |
| Endodontics (root canals) | 70% coinsurance(limits apply) |
| Periodontics (gum disease) | 70% coinsurance(limits apply) |
| Dentures and other removable prosthodontics | Optional supplemental benefit (extra premium) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Optional supplemental benefit (extra premium) |
| Oral and maxillofacial surgery | 50% coinsurance(limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | $0–$30 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $275 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $30 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $399–$699 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $125 allowance every three months |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $5.00 |
| Tier 3 | 25% |
| Tier 4 | 40% |
| Tier 5 | 33% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $5.00 | $5.00 | $0.00 | $15.00 | $15.00 | $0.00 |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 40% | 40% | 40% | 40% | 40% | 40% |
| Tier 5: Specialty Tier | 33% | 33% | 33% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 29 other OH counties
Benefits in plain text
Mount Carmel MediGold Premier (HMO) (H3668-018-1) is a 2026 HMO Medicare Advantage plan offered by MediGold, available to residents of Gallia County, OH.
The monthly premium is $102.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $88.80.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $3,900.00.
The drug deductible is $0.00.
The plan's formulary lists 3,507 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $5.00; tier 3: 25%; tier 4: 40%; tier 5: 33%.
CMS gives the plan's contract (H3668) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.