Gold Heart & Diabetes (HMO-POS C-SNP)
Available to residents of Cochise County, AZ for 2027. Contract H4869, plan 011, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Cochise County
- Plan website
- Browse the Gold Heart & Diabetes (HMO-POS C-SNP) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed for 2027. CMS carries this plan forward from 2026. Every AZ plan’s 2026–2027 changes →
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 |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $3,900.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO-POS C-SNP? |
| Special needs plan | Chronic-condition SNP |
| Qualifying condition | CardiovascularDisorders,ChronicHeartFailure,DiabetesMellitus |
| Contract / plan | H4869-011-0 |
| Offered by | Gold Kidney Health Plan |
| Parent organization | Gold Kidney Health Plan |
| Formulary tiers | 6 |
| Formulary exception tier | 4? |
| Pharmacy search | goldkidney.com/2023-care-directory |
| Member services | (844)294-6535TTY 711 |
CMS star ratings
- Overall
- 2.5 out of 5 stars for Overall
- Health plan (Part C)
- 2.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 2 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H4869 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0–$60 copay(authorization required) |
| Other health care professional | $0–$60 copay |
| Additional telehealth services | $0 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 | $0–$30 copay(authorization required) |
| Lab services | $0–$30 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$200 copay(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $0 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $120 copay |
| Urgent care | $40 copay |
| Worldwide emergency coverage | $120 copay · $75,000 plan limit |
| Worldwide urgent care | $120 copay · $75,000 plan limit |
| Worldwide emergency transportation | $120 copay |
| Hospital care | |
| Inpatient hospital stay | $220 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient hospital services | $0–$220 copay(authorization required) |
| Outpatient observation | $220 copay(authorization required) |
| Ambulatory surgical center | $0–$100 copay(authorization required) |
| Outpatient blood services | 20% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $217 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $15 copay |
| Physical therapy and speech-language therapy | $15 copay |
| Cardiac rehabilitation | $0 copay(authorization required) |
| Pulmonary rehabilitation | $10 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $220 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient mental health, individual session | $25 copay |
| Outpatient mental health, group session | $10 copay |
| Psychiatrist, individual session | $25 copay |
| Psychiatrist, group session | $10 copay |
| Partial hospitalization | $80 copay |
| Intensive outpatient program | $80 copay |
| Outpatient substance use, individual session | $25 copay |
| Outpatient substance use, group session | $15 copay |
| Opioid treatment program | $25 copay |
| Ambulance and transportation | |
| Ground ambulance | $200 copay(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | Not covered |
| 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 | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $20 copay |
| Routine chiropractic care | $20 copay(limits apply) |
| Acupuncture | $20 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $15 copay |
| Routine foot care | $15 copay(limits apply) |
| Dental? | |
| Medicare-covered dental services | $0 copay |
| Preventive dental plan limit | $1,000 plan limit every year |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | $0 copay(limits apply) |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| 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 | $0 copay(authorization required, limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required, limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| 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) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $195–$1,395 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 | Not covered |
| Meals after a hospital stay or for a chronic condition | $0 copay(referral required) |
| Fitness benefit | $0 copay(referral required) |
| Health education | $0 copay(referral required) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | $0 copay(referral required) |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | $0 copay(referral required) |
| In-home safety assessment | $0 copay(referral required) |
| Personal emergency response system (PERS) | $0 copay(referral required) |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | $0 copay(referral required) |
| Re-admission prevention | $0 copay(referral required) |
| 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 | $0 copay(referral required) |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). 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 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $5.00 |
| Tier 3 · Preferred Brand | $45.00 |
| Tier 4 · Non-Preferred Brand | 30% |
| Tier 5 · Specialty Tier | 33% |
| Tier 6 · Select Diabetic Drugs | $0.00 |
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 | $5.00 | $15.00 | $15.00 | $12.00 |
| Tier 3: Preferred Brand | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $112.00 |
| Tier 4: Non-Preferred Brand | 30% | 30% | 30% | 30% | 30% | 30% |
| Tier 5: Specialty Tier | 33% | 33% | n/a | n/a | n/a | n/a |
| Tier 6: Select Diabetic Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 3 out of 5 stars for Breast Cancer Screening | not enough data |
| Colorectal Cancer Screening · C02 | 1 out of 5 stars for Colorectal Cancer Screening | 1 out of 5 stars for Colorectal Cancer Screening |
| Annual Flu Vaccine · C03 | 3 out of 5 stars for Annual Flu Vaccine | 3 out of 5 stars for Annual Flu Vaccine |
| Monitoring Physical Activity · C06 | 3 out of 5 stars for Monitoring Physical Activity | 5 out of 5 stars for Monitoring Physical Activity |
| Managing Chronic (Long Term) Conditions | ||
| Special Needs Plan (SNP) Care Management · C07 | 3 out of 5 stars for Special Needs Plan (SNP) Care Management | 4 out of 5 stars for Special Needs Plan (SNP) Care Management |
| Care for Older Adults – Medication Review · C08 | 2 out of 5 stars for Care for Older Adults – Medication Review | 3 out of 5 stars for Care for Older Adults – Medication Review |
| Care for Older Adults - Functional Status Assessment · C09 | 2 out of 5 stars for Care for Older Adults - Functional Status Assessment | new measure |
| Diabetes Care – Eye Exam · C11 | 1 out of 5 stars for Diabetes Care – Eye Exam | 1 out of 5 stars for Diabetes Care – Eye Exam |
| Diabetes Care – Blood Sugar Controlled · C12 | 2 out of 5 stars for Diabetes Care – Blood Sugar Controlled | 1 out of 5 stars for Diabetes Care – Blood Sugar Controlled |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 4 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | 5 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes |
| Controlling High Blood Pressure · C14 | 2 out of 5 stars for Controlling High Blood Pressure | 3 out of 5 stars for Controlling High Blood Pressure |
| Reducing the Risk of Falling · C15 | 3 out of 5 stars for Reducing the Risk of Falling | not enough data |
| Plan All-Cause Readmissions · C17 | 3 out of 5 stars for Plan All-Cause Readmissions | no data |
| Statin Therapy for Patients with Cardiovascular Disease · C18 | 1 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease | not enough data |
| Transitions of Care · C19 | 2 out of 5 stars for Transitions of Care | 1 out of 5 stars for Transitions of Care |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 3 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 3 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 3 out of 5 stars for Getting Needed Care | 3 out of 5 stars for Getting Needed Care |
| Getting Appointments and Care Quickly · C22 | 3 out of 5 stars for Getting Appointments and Care Quickly | 2 out of 5 stars for Getting Appointments and Care Quickly |
| Customer Service · C23 | 1 out of 5 stars for Customer Service | 2 out of 5 stars for Customer Service |
| Rating of Health Care Quality · C24 | 2 out of 5 stars for Rating of Health Care Quality | 3 out of 5 stars for Rating of Health Care Quality |
| Rating of Health Plan · C25 | 5 out of 5 stars for Rating of Health Plan | 4 out of 5 stars for Rating of Health Plan |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 3 out of 5 stars for Complaints about the Health Plan | not enough data |
| Members Choosing to Leave the Plan · C28 | 4 out of 5 stars for Members Choosing to Leave the Plan | 4 out of 5 stars for Members Choosing to Leave the Plan |
| Health Plan Quality Improvement · C29 | 3 out of 5 stars for Health Plan Quality Improvement | not enough data |
| Health Plan Customer Service | ||
| Plan Makes Timely Decisions about Appeals · C30 | 1 out of 5 stars for Plan Makes Timely Decisions about Appeals | 5 out of 5 stars for Plan Makes Timely Decisions about Appeals |
| Reviewing Appeals Decisions · C31 | 1 out of 5 stars for Reviewing Appeals Decisions | 2 out of 5 stars for Reviewing Appeals Decisions |
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 2 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 3 out of 5 stars for Complaints about the Drug Plan | not enough data |
| Members Choosing to Leave the Plan · D03 | 4 out of 5 stars for Members Choosing to Leave the Plan | 4 out of 5 stars for Members Choosing to Leave the Plan |
| Drug Plan Quality Improvement · D04 | 1 out of 5 stars for Drug Plan Quality Improvement | not enough data |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 4 out of 5 stars for Rating of Drug Plan | 4 out of 5 stars for Rating of Drug Plan |
| Getting Needed Prescription Drugs · D06 | 1 out of 5 stars for Getting Needed Prescription Drugs | 3 out of 5 stars for Getting Needed Prescription Drugs |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 5 out of 5 stars for MPF Price Accuracy | 4 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 1 out of 5 stars for Medication Adherence for Diabetes Medications | 4 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 1 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 2 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 1 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 2 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 3 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 4 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 5 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 3 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H4869 shares it.
Also available in 3 other AZ counties
Benefits in plain text
Gold Heart & Diabetes (HMO-POS C-SNP) (H4869-011-0) is a 2027 HMO-POS C-SNP Medicare Advantage plan offered by Gold Kidney Health Plan, available to residents of Cochise County, AZ.
The monthly premium is $0.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
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.
It is a special needs plan (Chronic-condition SNP).
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $5.00; tier 3 (Preferred Brand): $45.00; tier 4 (Non-Preferred Brand): 30%; tier 5 (Specialty Tier): 33%; tier 6 (Select Diabetic Drugs): $0.00.
CMS gives the plan's contract (H4869) an overall rating of 2.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.