Geisinger Gold Preferred Complete Rx (PPO)

Available to residents of Lehigh County, PA for 2026. Contract H3924, plan 065, segment 0.

Renewed for 2026. CMS carries this plan forward from 2025.

Plan details

Monthly premium (Part C + D)	$0.00
— medical (Part C) part	$0.00
— drug (Part D) part	$0.00?
Monthly premium with full Extra Help (LIS)	$0.00?
Part B premium reduction (giveback)	None
In-network out-of-pocket maximum	$7,200.00?
In- and out-of-network out-of-pocket maximum	$7,200.00
Drug deductible	$0.00
Drug out-of-pocket threshold	$2,100.00
Plan type	PPO?
Contract / plan	H3924-065-0
Offered by	Geisinger Gold
Parent organization	Risant Health, Inc.
Formulary drugs	3,659
Formulary exception tier	4?
Pharmacy search	www.geisinger.org/health-plan/find/covered-drug-pharmacy/medicare-dsnp
Member services	(800)514-0138TTY 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): 4.5 out of 5 stars for Drug plan (Part D)

Published per contract — every plan under contract H3924 shares this rating.

Plan health benefits

Service	In-network	Out-of-network?
Doctor visits
Primary care doctor	$0 copay	$0 copay
Specialist	$35 copay(authorization required)	$35 copay
Other health care professional	$0–$35 copay(authorization required)	$0–$35 copay
Additional telehealth services	$0–$35 copay	—
Preventive care
Medicare-covered preventive services	$0 copay	$0 copay
Annual physical exam	$0 copay	$0 copay
Kidney disease education	$0 copay	$0 copay
Glaucoma screening	$0 copay	$0 copay
Diabetes self-management training	$0 copay	$0 copay
Diagnostic tests, labs and imaging
Diagnostic tests and procedures	$20 copay(authorization required)	$20 copay
Lab services	$20 copay(authorization required)	$20 copay
Diagnostic radiology (e.g. MRI, CT)	$0–$290 copay(authorization required)	$0–$290 copay
Therapeutic radiology	$40–$60 copay(authorization required)	$40–$60 copay
Outpatient x-rays	$40 copay(authorization required)	$40 copay
Emergency and urgent care
Emergency room	$115 copay	—
Urgent care	$35 copay	—
Worldwide emergency coverage	$115 copay · $100,000 plan limit	—
Worldwide urgent care	$35 copay · $100,000 plan limit	—
Worldwide emergency transportation	$275–$1,000 copay	—
Hospital care
Inpatient hospital stay	$225 per day for days 1–6; $0 per day for days 7–90(authorization required)	$225 per day for days 1–6; $0 per day for days 7–90
Outpatient hospital services	$0–$350 copay(authorization required)	$0–$350 copay
Outpatient observation	$0–$350 copay(authorization required)	$0–$350 copay
Ambulatory surgical center	$0–$350 copay(authorization required)	$0–$350 copay
Outpatient blood services	$0 copay	$0 copay
Skilled nursing and home health
Skilled nursing facility	$0 per day for days 1–20; $160 per day for days 21–65; $0 per day for days 66–100(authorization required)	$0 per day for days 1–20; $160 per day for days 21–70; $0 per day for days 71–100
Home health care	$0 copay(authorization required)	$0 copay
Kidney dialysis	10%–20% coinsurance	20% coinsurance
Rehabilitation
Occupational therapy	$35 copay(authorization required)	$35 copay
Physical therapy and speech-language therapy	$35 copay(authorization required)	$35 copay
Cardiac rehabilitation	$20 copay(authorization required)	$20 copay
Pulmonary rehabilitation	$15 copay(authorization required)	$15 copay
Mental health and substance use
Inpatient psychiatric hospital stay	$225 per day for days 1–6; $0 per day for days 7–90(authorization required)	$225 per day for days 1–6; $0 per day for days 7–90
Outpatient mental health, individual session	$10 copay	$10 copay
Outpatient mental health, group session	$5 copay	$5 copay
Psychiatrist, individual session	$10 copay	$10 copay
Psychiatrist, group session	$5 copay	$5 copay
Partial hospitalization	$55 copay(authorization required)	$55 copay
Intensive outpatient program	$55 copay(authorization required)	$55 copay
Outpatient substance use, individual session	$10 copay(authorization required)	$10 copay
Outpatient substance use, group session	$5 copay(authorization required)	$5 copay
Opioid treatment program	20% coinsurance(authorization required)	20% coinsurance
Ambulance and transportation
Ground ambulance	$275 copay(authorization required)	$275 copay
Air ambulance	$275 copay(authorization required)	$275 copay
Transportation to plan-approved locations	Not covered	—
Medical equipment and supplies
Durable medical equipment (e.g. wheelchairs, oxygen)	20% coinsurance(authorization required)	20% coinsurance
Prosthetics (e.g. braces, artificial limbs)	20% coinsurance(authorization required)	20% coinsurance
Medical supplies	20% coinsurance(authorization required)	20% coinsurance
Diabetes supplies	0%–20% coinsurance(authorization required)	0%–20% coinsurance
Diabetic therapeutic shoes or inserts	20% coinsurance(authorization required)	20% coinsurance
Chiropractic, acupuncture and foot care
Chiropractic (Medicare-covered)	$15 copay	$15 copay
Routine chiropractic care	Not covered	—
Acupuncture	Not covered	—
Foot exams and treatment (Medicare-covered)	$35 copay	$35 copay
Routine foot care	$0 copay(limits apply)	$0 copay
Dental?
Medicare-covered dental services	$35 copay(authorization required)	$35 copay
Oral exams	Not covered	—
Cleanings	Not covered	—
Fluoride treatment	Not covered	—
Dental x-rays	Not covered	—
Other diagnostic dental services	Not covered	—
Other preventive dental services	Not covered	—
Restorative services (fillings, crowns)	Not covered	—
Endodontics (root canals)	Not covered	—
Periodontics (gum disease)	Not covered	—
Dentures and other removable prosthodontics	Not covered	—
Maxillofacial prosthetics	Not covered	—
Implants	Not covered	—
Bridges and other fixed prosthodontics	Not covered	—
Oral and maxillofacial surgery	Not covered	—
Orthodontics	Not covered	—
Adjunctive general services	Not covered	—
Vision?
Eye exam (Medicare-covered)	$0–$35 copay	$0–$35 copay
Routine eye exam	Not covered	—
Eyewear after cataract surgery (Medicare-covered)	$0 copay	$0 copay
Contact lenses	Not covered	—
Eyeglasses (frames and lenses)	Not covered	—
Eyeglass lenses	Not covered	—
Eyeglass frames	Not covered	—
Eyewear upgrades	Not covered	—
Hearing?
Hearing exam (Medicare-covered)	$35 copay	$35 copay
Routine hearing exam	Not covered	—
Hearing aid fitting and evaluation	Not covered	—
Hearing aids (all types)	Not covered	—
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	0%–20% coinsurance(authorization required, step therapy may apply)	$0–$35 copay; 0%–20% coinsurance
Chemotherapy and radiation drugs	0%–20% coinsurance(authorization required, step therapy may apply)	0%–20% coinsurance
Other Part B drugs	0%–20% coinsurance(authorization required, step therapy may apply)	0%–20% coinsurance
Other extra benefits?
Over-the-counter (OTC) allowance	Not covered	—
Meals after a hospital stay or for a chronic condition	Not covered	—
Fitness benefit	Not covered	—
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	$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; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.

Drug tiers — preferred pharmacy, initial coverage

Tier	Cost-sharing
Tier 1	$2.00
Tier 2	$20.00
Tier 3	25%
Tier 4	34%
Tier 5	33%
Tier 6	$0.00

Rx cost-sharing by coverage phase

Tier	30-day supply			90-day supply
Tier	Preferred	Standard	Mail Order	Preferred	Standard	Mail Order
Initial coverage phase
Tier 1: Preferred Generic	$2.00	$2.00	$0.00	$5.00	$5.00	$0.00
Tier 2: Generic	$20.00	$20.00	$0.00	$50.00	$50.00	$0.00
Tier 3: Preferred Brand	25%	25%	25%	25%	25%	25%
Tier 4: Non-Preferred Drug	34%	34%	34%	34%	34%	34%
Tier 5: Specialty Tier	33%	33%	33%	n/a	n/a	n/a
Tier 6: Select Care Drugs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
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
Tier 6: Select Care Drugs	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

Also available in 43 other PA counties

Benefits in plain text

Geisinger Gold Preferred Complete Rx (PPO) (H3924-065-0) is a 2026 PPO Medicare Advantage plan offered by Geisinger Gold, available to residents of Lehigh County, PA.

The monthly premium is $0.00 (Part C and Part D together).

With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.

Its in-network out-of-pocket maximum is $7,200.00.

The combined in- and out-of-network out-of-pocket maximum is $7,200.00.

The drug deductible is $0.00.

The plan's formulary lists 3,659 drugs.

At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $2.00; tier 2: $20.00; tier 3: 25%; tier 4: 34%; tier 5: 33%; tier 6: $0.00.

CMS gives the plan's contract (H3924) 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.