Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.
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Your Guide to
Geisinger Gold
We’ll help you choose the Medicare
Advantage Plan that’s right for you.
APB_PA_CORE_2015
Y0032_H8468_14202_3
CMS Approved 8/11/14
We’ll help you every step of the way. If you want to lower your health care expenses, look no further than Geisinger Gold. We make it easy for you to get the affordable health care protection you need. You can speak with a Geisinger Gold Sales Counselor who understands your concerns, listens to your needs, and gives you the kind of straightforward information you need to make the best decision. There’s no obligation. Call us today, and we can help you enroll right over the phone! For your convenience, you can also enroll online at GeisingerGold.com. To Find Out More … Call 1-800-823-9633 today! TDD: 711 8 a.m. to 8 p.m., (7 days a week, Oct 1. - Feb. 14) 8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30) GeisingerGold.com Cover Photo: tecmc/iStock/Thinkstock
Table of Contents What makes Geisinger Gold a smart choice for me? .................................................4 Get more for your money ...........................................................................................5 Choosing the best plan for you ..................................................................................6 Medicare Advantage Plan Overview ..........................................................................7-8 What is a Medicare Advantage plan?.........................................................................9 Are prescription drugs covered? ................................................................................9 What if I spend time outside the Geisinger Gold service area? ................................9 Are my doctors in the network? ................................................................................9 Who is eligible? .........................................................................................................9 When can I enroll? .....................................................................................................9 Do I qualify for a low income subsidy? .....................................................................10 How do I enroll? ........................................................................................................10 When will my coverage become effective? ...............................................................10 What if I change my mind?........................................................................................10 Here’s what you’ll pay with Geisinger Gold Medicare Prescription Drug Coverage (Part D) .........................................................................11-12 Medicare Advantage Benefits Overview....................................................................13-18 Geisinger Gold Health+ Benefits ...............................................................................19 2015 Medicare Advantage Premiums ........................................................................20 What else should I know about Medicare Advantage plans?.....................................22
BananaStock/BananaStock/Thinkstock
To Find Out More …
Call 1-800-823-9633 today!
TDD: 711
8 a.m. to 8 p.m., (7 days a week, Oct. 1. - Feb. 14)
8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30)
GeisingerGold.com
What makes Geisinger Gold a smart choice for me?
Geisinger Gold is the #1 ranked Medicare
Advantage plan in Pennsylvania, and one
of the top ten in the nation.*
Begun in 1994, Geisinger Gold serves more than 79,000 members.
Geisinger Gold has held the highest accreditation level from the
National Committee for Quality Assurance (NCQA) since 2006.
Dedicated to Better Health
“Providing quality health care coverage at
affordable costs is Geisinger Gold’s primary mission.
For nearly 20 years, we’ve been dedicated to
working with physicians and hospitals to provide
superior health care coverage to the residents
in the counties we serve. Our position as the #1
ranked Medicare Advantage plan in Pennsylvania
and one of the top ten in the nation* is proof of
our dedication to our members.”
Steven R. Youso
President and CEO
Geisinger Health Plan
*NCQA’s Medicare Health Insurance Plan Rankings 2013-2014.
For more information about the rankings, please visit
http://www.ncqa.org/Directories/HealthPlans/HealthInsurancePlanRankings/
MedicaidandMedicareHealthPlanRankings201314.aspx
Geisinger Gold Medicare Advantage 4
Get more for your money.
When you join a Geisinger Gold Medicare Advantage plan, you continue to get all of your
Medicare Part A & B benefits. Geisinger Gold Medicare Advantage plans also include a wide
range of cost-saving features and wellness programs not available with Medicare Parts A and
B.
Geisinger Gold
Medicare Parts A and B
Medicare Advantage plans
Plans starting at $0 a month; you
You must pay your
Low Cost must continue to pay your Part B
Part B premium
premium.
Prescription drug coverage with
Prescription Drug No generic drug copays as low as $3
is available.
Yes: Most plans have an annual
Out-of-Pocket Protection No limit on how much you pay in
deductibles and copays.
Included with some plans, optional
Routine Dental Services No
with others.
Included with some plans, optional
Hearing Aid Benefit No
with others.
Routine Vision/ Eyewear Included with some plans, optional
No
Benefits with others.
Included with some plans, optional
Fitness Benefits No
with others.
Care Management
Programs for heart Yes, with our Classic (HMO),
conditions, diabetes, blood No Preferred (PPO) and
pressure, kidney disease Secure (HMO SNP) plans.
and much, much, more!
Coverage of preventive Services covered with $0 copay
services, including certain for all Geisinger Gold plans
Yes
health screenings and (For Reserve (MSA) plan,
immunizations deductible must be met).
5 Geisinger Gold Medicare AdvantageChoosing the best plan for you
Geisinger Gold offers a wide-array of health plans which include: traditional HMO, Preferred
Provider Organization (PPO), Special Needs Plans, and Medical Savings Account (MSA).
While each of the plans we offer will provide you with outstanding health care coverage, finding
the right plan for you is too important to leave to guesswork. That’s why Geisinger Gold Sales
Counselors provide expertise and guidance that makes it easy for you to get the affordable health
coverage you want. In fact, we can walk you through the entire process … answering all your
questions and helping you enroll in a plan that fits both your needs and budget.
Geisinger Gold offers a variety of choices. To get started, think about what’s important to you.
If you want a plan that’s easy on the budget, consider one of our Medicare Advantage HMO
or PPO plans. They offer broad coverage, low out-of-pocket costs and a provider network that
includes over 29,000 providers and over 90 hospitals.
If you have full Medicaid benefits in addition to Medicare, our Special Needs Plan, Secure Rx,
may be right for you.
If flexibility is important to you, consider our Reserve (MSA) plan. It offers the freedom to
choose any doctor or hospital, anywhere in the U.S., that accepts Medicare and agrees to see you.
Jupiterimages/Stockbyte/Thinkstock
Geisinger Gold Medicare Advantage 6Medicare Advantage Plan Overview
Geisinger Gold Classic (HMO) plans Geisinger Gold Preferred (PPO) plans
Geisinger Gold Classic (HMO) plans are HMO Geisinger Gold Preferred (PPO) is a PPO plan that
plans that offer more comprehensive protection offers predictable costs and the freedom to choose
and lower out-of-pocket costs than you get with any doctor or hospital you wish. No Primary Care
Original Medicare. A Primary Care Physician Physician selection or referrals are needed. You
works to coordinate your medical care. Covered can use any provider who is part of our network,
services including hospitalization, routine office and you have the flexibility to use out-of-network
visits, physicals, immunizations, diagnostic tests providers at a higher out-of-pocket cost.
and x-rays, are covered with affordable, predictable
costs.
Geisinger Gold Secure
(HMO SNP) plan
Geisinger Gold Secure (HMO SNP) is a Special
Needs HMO plan for individuals who meet certain
income or need-based criteria. If you are fully
eligible for both Medicare and Medicaid this plan
may be right for you. Prescription drug coverage
is included.
Wavebreakmedia Ltd/Wavebreak Media/Thinkstock
7 Geisinger Gold Medicare AdvantageGeisinger Gold Reserve (MSA) plan
Available statewide, this Medicare Advantage Plan option puts you in control of your health care dollars. It
combines a high-deductible insurance plan with a savings account to pay your medical bills. There’s no
monthly premium and you have the freedom to choose any medical professional who accepts Medicare and
agrees to see you. Here’s how it works:
Geisinger Gold deposits $1,020 a year (provided by Medicare) into your Medical Savings Account to help pay
qualified medical expenses such as doctor visits, diagnostics tests such as X-rays, inpatient hospital stays, etc.
This $1,020 can help meet your annual $3,600 deductible. Once the deductible is met, Geisinger Gold pays
all Medicare covered expenses in full. Any money left in your Medical Savings Account at the end of the
calendar year rolls over to the next year.
Example 1: Over time, your MSA account can pay for plan-covered expenses, resulting in no cost to you. You
can use the funds deposited to your MSA account first to pay for medical expenses. If you do not use all the
money in your MSA account, that money carries over to the next year, and is added to your annual deposit.
The funds in your MSA account can build over time to meet your full annual deductible.
$3,600 Annual Deductible - Geisinger Gold Pays Costs After Deductible is Met
Account
Balance
Account (Carry Medical
Balance Over+ Costs
Account
(Carry Balance Deposit) Paid
Balance
(Deposit) Over + Carry by MSA
Medical
Balance Deposit) Medical Over $1,760 Account Balance
Costs
Carry Costs to New Carry
$1,020 Paid
Over $1,540 Paid Year $900 Over
by MSA
to New by MSA to New
Account
Year Account $740 Year
$500
$520 $800 $860
Year 1 Year 2 Year 3
In each year, medical costs are less than the MSA account balance, resulting in no cost to you, and a higher
starting balance each new year due to carry over.
Example 2: Plan-Covered Expenses Exceed the Deductible
$6,400
For the year, your
medical costs total $2,580
$10,000 (to meet
$1,020
$3,600
deductible)
MSA You Geisinger
Account Pay Gold
Pays Pays
Geisinger Gold Medicare Advantage 8Geisinger Gold Medicare Advantage
Answers to frequently asked questions
What is a Medicare Advantage Are my doctors in the network?
plan? Visit GeisingerGold.com for the most up-to
Medicare Advantage plans were created to date information about our network. There
give Medicare recipients greater benefits you will find information about the Health
than original Medicare (Medicare Parts A Plan’s participating primary care physicians,
& B) alone. They follow guidelines set by specialists, mental health providers, hospitals
Medicare, but may offer a wide variety of and other services, including durable medical
additional benefits and plan options. When equipment vendors, radiology facilities and
you’re insured with a Medicare Advantage more. You can also call a Geisinger Gold Sales
plan, you still have Medicare. But your Counselor who will help you find a doctor and
coverage is administered by a private company, answer any questions you may have.
rather than by the government. So instead of
presenting your Medicare Card for services, Who is eligible?
you’ll use your Medicare Advantage Card. You are eligible to join a Geisinger Gold
Medicare Advantage plan as long as you have
Are prescription drugs covered? Medicare Parts A and B; live in the health
Yes! With Geisinger Gold, you can get all your plan’s service area; and do not have End-Stage
coverage from a single source, with generic Renal Disease (ESRD). If you are interested
drug copays as low as $3. in Geisinger Gold Reserve (MSA), additional
restrictions may apply.
You may be able to get extra help to pay for
your prescription drug premiums and costs. To When can I enroll?
see if you qualify for getting extra help, call:
1-800-MEDICARE (1-800-633-4227). TTY/ Medicare beneficiaries can enroll for Geisinger
TDD users should call 1-877-486-2048, 24 Gold Medicare Advantage coverage at certain
hours a day/7 days a week; The Social Security times of the year.
Administration at 1-800-772-1213 between Annual Election Period - Oct. 15 - Dec. 7
7:00 a.m. and 7:00 p.m., Monday through
Friday. TTY/TDD users should call 1-800 You can enroll in or switch to a new Medicare
325-0778; or your state Medicaid office. Advantage plan or Medicare Advantage
prescription drug plan during the Annual
What if I spend time outside the Election Period (AEP). For 2015 coverage, the
Geisinger Gold service area? Annual Election Period is from October 15 to
December 7, 2014.
Medical emergency services are covered
worldwide under all of our HMO and PPO
plans. Geisinger Gold Preferred (PPO) plans
have in- and out-of-network coverage, with no
referrals required. Your out-of-pocket expenses
will be higher if you use providers who are not
members of the network.
Geisinger Gold Reserve (MSA) members can
go to any medical professional that accepts
Medicare and agrees to see them.
9 Geisinger Gold Medicare AdvantageGeisinger Gold Medicare Advantage
Answers to frequently asked questions
Initial Coverage Election Period How do I enroll?
When you turn 65 (or when you retire) or We make enrollment easy. During the
otherwise become eligible for Medicare, you Annual Election Period for Medicare
qualify for an Initial Election Period. This beneficiaries, you can talk to one of our
is usually a seven-month period that begins local Geisinger Gold Sales Counselors
three months before your birthday month for advice and assistance. Once you
the month of and 3 months after you are first decide what plan is right for you, the Sales
eligible for both Medicare Part A and Part B. Counselor can complete your enrollment
Beyond your Initial Election Period, certain right over the phone! You can also visit
circumstances may make you eligible to GeisingerGold.com for plan information
enroll for coverage at any time. Eligibility and to enroll online. In-person enrollment
for these Special Election Periods include meetings may also be available.
a change in residence, delayed retirement,
disability, loss of benefits if your existing When will my coverage become
plan’s contract is not renewed by Medicare, effective?
loss of low income subsidy or special needs If you enroll between October 15 and
status. Please call for more information. December 7, 2014, your coverage will
become effective on January 1, 2015.
Do I qualify for a low income
subsidy? What if I change my mind?
If you have limited resources and income, Between January 1 and February 14, you
you may be eligible for a Low Income can disenroll from a Medicare Advantage
Subsidy. This subsidy provides help with plan and return to Original Medicare. As a
monthly premiums, annual deductibles, result of this change, you would be eligible
and prescription drug copayments related to enroll in a stand-alone Prescription Drug
to a Medicare prescription drug plan. Plan (PDP). You will not be able to make
Incremental and full subsidies are awarded, any further changes until the next Annual
based on income and asset testing using Election Period (unless you qualify for a
federal guidelines. Low Income Subsidies special election period during the year). The
are administered by the Social Security annual disenrollment period does not apply
Administration and the Center for Medicare for Geisinger Gold Reserve (MSA).
and Medicaid Services.
To Find Out More …
Call 1-800-823-9633 today!
TDD: 711
8 a.m. to 8 p.m., (7 days a week, Oct. 1. - Feb. 14)
8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15. - Sept. 30)
GeisingerGold.com
Geisinger Gold Medicare Advantage 10Here’s what you’ll pay with
Geisinger Gold Medicare Prescription
Drug Coverage (Part D).
Classic Complete Rx, Preferred Complete Rx, Preferred Essential Rx
Annual Deductible: $0
Initial Coverage
Until total yearly drug costs reach $2,960, a member pays:
Retail Tier 1: $6 copay for 1 month (30 day) supply, $18 copay for 3 month (90 day) supply
Retail Tier 2: $20 copay for 1 month (30 day) supply, $60 copay for 3 month (90 day) supply
Retail Tier 3: $39 copay for 1 month (30 day) supply, $117 copay for 3 month (90 day) supply
Retail Tier 4: $85 copay for 1 month (30 day) supply, $255 copay for 3 month (90 day) supply
Retail Tier 5: 33% coinsurance for one month (30 day) supply
Classic Advantage Rx, Preferred Advantage Rx, Preferred Select Rx
Annual Deductible: $0
Initial Coverage
Until total yearly drug costs reach $2,960, a member pays:
Retail Tier 1: $3 copay for 1 month (30 day) supply, $9 copay for 3 month (90 day) supply
Retail Tier 2: $18 copay for 1 month (30 day) supply, $54 copay for 3 month (90 day) supply
Retail Tier 3: $39 copay for 1 month (30 day) supply, $117 copay for 3 month (90 day) supply
Retail Tier 4: $85 copay for 1 month (30 day) supply, $255 copay for 3 month (90 day) supply
Retail Tier 5: 33% coinsurance for one month (30 day) supply
11 Geisinger Gold Medicare AdvantageCoverage Gap (all plans)
After total yearly drug costs reach $2,960, but before a member’s yearly out-of-pocket reaches
$4,700, members enter the coverage gap. While in the gap, Geisinger Gold members still have
access to Tier 1 generic medications for as low as $3 (depending on your plan) for a 30-day
supply. For other medications, member pays 65% of the cost for the generic medications and
45% of the cost for brand medications. For example, you would pay $45 for a $100 brand-name
drug and $6.50 for a $10 generic version of that drug.
Catastrophic Coverage (all plans)
After yearly out-of-pocket drug costs reach $4,700, a member pays $2.65 copay for generic
(including brand drugs treated as generic) and $6.60 copay for all other drugs or 5% coinsurance,
whichever amount is greater.
Secure Rx
Annual Deductible: $0 annual deductible*
Depending on your level of Extra Help, you pay the following*:
For generic drugs (including brand drugs treated as generic), either:
- A $0 copay or
- A $1.20 copay or
- A $2.65 copay
For all other drugs, either:
- A $0 copay or
- A $3.60 copay or
- A $6.60 copay.
After your yearly out-of-pocket drug costs reach $4,700, you pay a $0 copay.*
*Note: Generally, members in Secure 1 will not be subject to a deductible or the coverage gap.
Members will pay low, predictable copays for their medications right away, depending on the
level of Extra Help they get from Medicare.
Geisinger Gold Medicare Advantage 12Medicare Advantage Benefits Overview
Medicare Advantage
premiums are located Classic Advantage (HMO) Classic Complete Rx (HMO)
on page 20 Member Responsibility Member Responsibility
Annual Medical Deductible No Deductible No Deductible
Annual Medical Out-of-Pocket $3,400 $6,700
Maximum
Inpatient Hospital Care $125 days 1-5 $190 days 1-7
$0 days 6-90 $0 days 8-90
Skilled Nursing Facility Care $40 days 1-20 $0 days 1-20
$75 days 21-54 $156 days 21-63
$0 days 55-100 $0 days 64-100
(no prior hospital stay required) (no prior hospital stay required)
Emergency Care/Urgent Care $65/$20 (Waived if admitted) $65/$35 (Waived if admitted)
Primary Care/Specialty Care $5/$20 $10/$35
Provider
Outpatient Lab/Diagnostic Tests $5/$5 $5/$5
Outpatient X-Rays $25 $30
Outpatient MRI, CT, PET Scans $100 per day 20%
Outpatient Ambulatory Surgery 20% 20%
Ambulance Services (each way) $100 (Waived if admitted) $175 (Waived if admitted)
Durable Medical Equipment 20% 20%
Medicare Part D Prescription Drug Available (for additional cost) Included
Coverage
Medicare-Covered Eyewear $0 $0
(Post-Cataract Surgery) Only Medicare-covered (Basic Only Medicare-covered (Basic
frames and lenses) frames and lenses)
Glaucoma screening (1 per year, $0 $0
office visit copay may apply)
Dental Services (Preventive): $20 for exam and cleaning every Optional with this plan as part
Exam, Cleaning, and X-Ray six months; $20 bitewing only and of the Health+ benefit package.
$30 panoramic and other types Please see page 19 for details.
every year
Routine Contact Lenses or $200 maximum benefit every two Optional with this plan as part
Eyeglasses (Lenses and Frames) years of the Health+ benefit package.
Please see page 19 for details.
Hearing Exams - Diagnostic $20, one per year Optional with this plan as part
Routine of the Health+ benefit package.
Please see page 19 for details.
Hearing Aids/Fitting for Hearing $800 maximum benefit every three Optional with this plan as part
Aids years (fitting and evaluation includ of the Health+ benefit package.
ed in this limit) Please see page 19 for details.
Fitness Benefits $90 every three months to pay for Optional with this plan as part
fitness center memberships or other of the Health+ benefit package.
eligible fitness costs Please see page 19 for details.
13 Geisinger Gold Medicare AdvantageSecure Rx (HMO SNP)*
Member Responsibility
Annual Medical Deductible None to Member; Medicare Fee-for-Service Deductible billed to
Medicaid
Annual Medical Out-of-Pocket $6,700
Maximum
Inpatient Hospital Care $0
Skilled Nursing Facility Care $0
Emergency Care/Urgent Care $0
Primary Care/Specialty Care Provider $0
Outpatient Lab/Diagnostic Tests $0
Outpatient X-Rays $0
Outpatient MRI, CT, PET Scans $0
Outpatient Ambulatory Surgery $0
Ambulance Services (each way) $0
Durable Medical Equipment $0
Over the Counter Medications and $50 allowance every 3 months
Supplies
Medicare Part D Prescription Drug Included
Coverage
Medicare-Covered Eyewear $0
(Post-Cataract Surgery)
Glaucoma screening (1 per year, office $0
visit copay may apply)
Dental Services (Preventive): Exam, $0 for exam, cleaning and x-ray, every 6 months; Max. $2,000/
Cleaning, and X-Ray year combined for all non-Medicare dental; Incl. simple fillings,
extractions and dentures
Routine Contact Lenses or Eyeglasses $200 maximum benefit every year
(Lenses and Frames)
Hearing Exams - Diagnostic Routine $0, one per year
Hearing Aids/Fitting for Hearing Aids $600 maximum benefit every three years (fitting and evaluation
included in this limit)
Fitness Benefits $90 every three months to pay for fitness center memberships or
other eligible fitness costs
*Secure Rx (HMO SNP) premiums and costs based on Medicaid eligibility
Geisinger Gold Medicare Advantage 14Medicare Advantage Benefits Overview
Medicare Advantage
premiums are located Preferred Advantage Rx (PPO)
on page 20 Member Responsibility
In-Network Out-of-Network
Annual Medical Deductible
$0 In/Out Combined
Annual Medical Out-of-Pocket $6,700; In-network only $10,000 in and out combined
Maximum
Inpatient Hospital Care $390 per stay 35%
Skilled Nursing Facility Care $0 days 1-20 35%
$156 days 21-63
$0 days 64-100
Emergency Care/Urgent Care $65/$35 (Waived if admitted)
Primary Care/Specialty Care $10/$35 35%/35%
Provider
Outpatient Lab/Diagnostic $20/$20 35%
Tests
Outpatient X-Rays $20 35%
Outpatient MRI, CT, PET 20% 35%
Scans
Outpatient Ambulatory Surgery 20% 35%
Ambulance Services (each $200 (Waived if admitted) $200 (Waived if admitted)
way)
Durable Medical Equipment 20% 20%
Medicare-Covered Eyewear $0 $0 after deductible
(Post-Cataract Surgery) Only Medicare-covered (Basic Only Medicare-covered
frames and lenses) (Basic frames and lenses)
Glaucoma screening (1 per $0 $0
year, office visit copay may
apply)
Medicare Part D Prescription Included
Drug Coverage
Geisinger Gold Health+ Provides coverage for preventive dental services, routine vision
Optional Benefits and hearing care, and fitness center benefits. Please see page 19
for details on this valuable benefits package.
15 Geisinger Gold Medicare AdvantagePreferred Complete Rx (PPO)
Member Responsibility
In-Network Out-of-Network
Annual Medical Deductible
$0 In/Out Combined
Annual Medical Out-of-Pocket $6,700; In-network only $10,000 in and out combined
Maximum
Inpatient Hospital Care $218 days 1-7 45%
$0 days 8-90
Skilled Nursing Facility Care $0 days 1-20 45%
$156 days 21-63
$0 days 64-100
Emergency Care/Urgent Care $65/$40 (Waived if admitted)
Primary Care/Specialty Care $10/$40 45%
Provider
Outpatient Lab/Diagnostic $25/$25 45%
Tests
Outpatient X-Rays $25 45%
Outpatient MRI, CT, PET 30% 45%
Scans
Outpatient Ambulatory 30% 45%
Surgery
Ambulance Services (each $190 (Waived if admitted) $190 (Waived if admitted)
way)
Durable Medical Equipment 20% 20%
Medicare-Covered Eyewear $0 $0 after deductible
(Post-Cataract Surgery) Only Medicare-covered (Basic Only Medicare-covered
frames and lenses) (Basic frames and lenses)
Glaucoma screening (1 per $0 $0
year, office visit copay may
apply)
Medicare Part D Prescription Included
Drug Coverage
Geisinger Gold Health+ Provides coverage for preventive dental services, routine vision
Optional Benefits and hearing care, and fitness center benefits. Please see page 19
for details on this valuable benefits package.
Geisinger Gold Medicare Advantage 16Medicare Advantage Benefits Overview
Medicare Advantage
premiums are located Preferred Select Rx (PPO)
on page 20 Member Responsibility
In-Network Out-of-Network
Annual Medical Deductible
$1,000 In/Out Combined
Annual Medical Out-of-Pocket $6,700; In-network only $10,000 in and out combined
Maximum
Inpatient Hospital Care $350 per stay after deductible 35% after deductible
Skilled Nursing Facility Care $0 days 1-20 35% after deductible
$156 days 21-57
$0 days 58-100
after deductible
Emergency Care/Urgent Care $65/$35 (Waived if admitted)
Primary Care/Specialty Care $10/$35 35% after deductible
Provider
Outpatient Lab/Diagnostic $20/$20 after deductible 35% after deductible
Tests
Outpatient X-Rays $20 after deductible 35% after deductible
Outpatient MRI, CT, PET 20% after deductible 35% after deductible
Scans
Outpatient Ambulatory Surgery $295 after deductible 35% after deductible
Ambulance Services (each $200 after deductible (Waived $200 after deductible (Waived
way) if admitted) if admitted)
Durable Medical Equipment 20% 20%
Medicare-Covered Eyewear $0 $0 after deductible
(Post-Cataract Surgery) Only Medicare-covered (Basic Only Medicare-covered
frames and lenses) (Basic frames and lenses)
Glaucoma screening (1 per $0 $0
year, office visit copay may
apply)
Medicare Part D Prescription Included
Drug Coverage
Geisinger Gold Health+ Provides coverage for preventive dental services, routine vision
Optional Benefits and hearing care, and fitness center benefits. Please see page 19
for details on this valuable benefits.
17 Geisinger Gold Medicare AdvantagePreferred Essential Rx (PPO)
Member Responsibility
In-Network Out-of-Network
Annual Medical Deductible
$1,000 In/Out Combined
Annual Medical Out-of-Pocket $6,700; In-network only $10,000 in and out combined
Maximum
Inpatient Hospital Care $218 days 1-7 35% after deductible
$0 days 8-90
Skilled Nursing Facility Care $0 days 1-20 35% after deductible
$156 days 21-57
$0 days 58-100
after deductible
Emergency Care/Urgent Care $65/$25 (Waived if admitted)
Primary Care/Specialty Care $15/$35 35% after deductible
Provider
Outpatient Lab/Diagnostic $25/$25 35% after deductible
Tests
Outpatient X-Rays $45 35% after deductible
Outpatient MRI, CT, PET 20% after deductible 35% after deductible
Scans
Outpatient Ambulatory Surgery 20% after deductible 35% after deductible
Ambulance Services (each way) $150 after deductible (Waived 35% after deductible (Waived if
if admitted) admitted)
Durable Medical Equipment 20% 35% after deductible
Medicare-Covered Eyewear $0 $0 after deductible
(Post-Cataract Surgery) Only Medicare-covered (Basic Only Medicare-covered
frames and lenses) (Basic frames and lenses)
Glaucoma screening (1 per $0 $0
year, office visit copay may
apply)
Medicare Part D Prescription Included
Drug Coverage
Geisinger Gold Health+ Provides coverage for preventive dental services, routine vision
Optional Benefits and hearing care, and fitness center benefits. Please see page 19
for details on this valuable benefits.
Geisinger Gold Medicare Advantage 18Geisinger Gold Health+ Benefits
Geisinger Gold is pleased to introduce Health+, a package of valuable benefits which are not
covered by Medicare. This package is designed to complement your Medicare Advantage plan
by providing coverage for routine dental services, vision services, hearing aids, and fitness ben-
efits. Health+ gives you more flexibility to spend your health care dollars the way you want and
need to, including the ability to join any fitness center you want!
Dental Services (Preventive): $250 every year to pay for:
Exam, Cleaning, and X-Ray 1 cleaning every six months
1 exam every six months
1 x-ray every year
Vision Exams - Diagnostic Routine $20 copay
(1 per year)
Routine Contact Lenses or $100 benefit maximum every year
Eyeglasses (Lenses and Frames)
Hearing Exams - Diagnostic $20 copay
Routine (1 per year)
Hearing Aids/Fitting for Hearing $250 maximum benefit every year
Aids (includes fitting and evaluation)
Fitness Benefits $90 reimbursement every three months
to pay for fitness center activities such
as memberships, classes, or training
sessions
These valuable benefits are included in Classic Advantage, Classic Advantage Rx and Secure
Rx. They can be added to the following plans for an additional monthly cost of $38:
• Classic Complete Rx
• Preferred Advantage Rx
• Preferred Complete Rx
• Preferred Select Rx
• Preferred Essential Rx
• Reserve
For more information on Geisinger Gold Medicare Advantage plans, please
visit GeisingerGold.com or call us today at 1-800-823-9633. Some dental
and vision services may be covered by Medicare. Call 1-800-823-9633 for details.
19 Geisinger Gold Medicare Advantage2015 Medicare Advantage Monthly Premiums
Susquehanna
otter
Potter Tioga
Wayne
Wyoming
Wyoming
ameron
Camer on Sullivan Lacka
Lack awanna
Lycoming Pike
Clinto
Clinton
Jefferson Luz
Luzerne
Columbia
Monroe
onroe
Clearfield Montour
ntour
Cen
Ce ntre Union Carbon
Northumberland
Snyder Nor
Sny thumberland
Northampt
Nor thampton
on
Schuylkill
chuylkill
Cambria Mifflin Lehigh
Juniata Dauphin
Blair Berks
Perrr y
Pe
Lebanon
Huntingdon
Cumberland
Lancaster
Lancast er
Somerset
ulton
Fult on Yor
York
Adams
Central Northeast South Southeast West
Plan Name Region Region Region Region Region
Classic Advantage $110 $95 $90 $50 $100
Classic Advantage Rx $149 $139 $124 $119 $129
Classic Complete Rx $0 $0 $0 $0 $0
Secure Rx* $0 $0 $0 $0 $0
Preferred Advantage Rx Not Available Not Available $70 $75 Not Available
Preferred Complete Rx Not Available Not Available $0 $0 Not Available
Preferred Select Rx $179 $159 Not Available Not Available $119
Preferred EssenƟal Rx** Not Available Not Available Not Available $31 Not Available
Geisinger Gold Reserve (MSA) available in all PA counties with $0 monthly premium
*Secure Rx (HMO SNP) premiums and costs based on Medicaid eligibility
**Preferred Essential Rx available in Carbon, Lehigh and Northampton counties only
Geisinger Gold Medicare Advantage 20FPO for image
Fuse/Thinkstock
To Find Out More …
Call 1-800-823-9633 today!
TDD: 711
8 a.m. to 8 p.m., (7 days a week, Oct. 1. - Feb. 14)
8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30)
GeisingerGold.com
21 Geisinger Gold Medicare AdvantageWhat else should I know about Medicare Advantage plans?
Geisinger Gold Medicare Advantage HMO, MSA Plans combine a high deductible
PPO, HMO POS, HMO SNP and MSA plans Medicare Advantage Plan and a trust or
are offered by Geisinger Health Plan/Geisinger custodial savings account (as defined and/or
Indemnity Insurance Company, health approved by the IRS). The plan deposits money
plans with a Medicare contract. Continued from Medicare into the account. You can use
enrollment in Geisinger Gold depends on this money to pay for your health care costs,
annual contract renewal. but only Medicare-covered expenses count
toward your deductible. The amount deposited
The benefit information provided is a brief is usually less than your deductible amount, so
summary, not a complete description of you generally have to pay out-of-pocket before
benefits. For more information contact the your coverage begins.
plan. Limitations, copayments, and restrictions
may apply. Benefits, formulary, pharmacy Medicare MSA Plans don’t cover prescription
network, premium and/or copayments/co drugs. If you join a Medicare MSA Plan,
insurance may change on January 1 of each you can also join any separate Medicare
year. You must continue to pay your Medicare Prescription Drug Plan.
Part B premium. Secure (HMO SNP) members
must meet certain eligibility requirements. You must file Form 1040, US Individual
Secure 1 (HMO SNP) costs may vary based Income Tax Return, along with Form 8853,
on the level of Extra Help you receive. Please “Archer MSA and Long-Term Care Insurance
contact the plan for further details. Contracts” with the Internal Revenue Service
(IRS) for any distributions made from your
A sales person will be present at meetings Medicare MSA account to ensure you aren’t
with information and applications. For taxed on your MSA account withdrawals. You
accommodation of persons with special needs must file these tax forms for any year in which
at sales meetings call 1-800-823-9633 (TDD an MSA account withdrawal is made, even if
users should call 711). you have no taxable income or other reason for
filing a Form 1040. MSA account withdrawals
Members must get their prescriptions from for qualified medical expenses are tax free,
network pharmacies. In case of emergency, while account withdrawals for non-medical
members may go to a non-network pharmacy. expenses are subject to both income tax and a
You may only enroll in one prescription drug fifty (50) percent tax penalty. Tax publications
plan at a time. If you are enrolled in a Medicare are available on the IRS website at http://www.
Advantage plan which offers prescription drug irs.gov or from 1-800-TAX-FORM
coverage, you must take your prescription drug (1-800-829-3676).
coverage from that plan.
There are additional restrictions to join an
Prescription drug coverage from Geisinger MSA plan, and enrollment is generally for
Gold is offered exclusively to Geisinger Gold a full calendar year unless you meet certain
members. You cannot enroll in a standalone exceptions. Those who disenroll during the
prescription drug plan, unless you disenroll calendar year will owe a portion of the account
from your Medicare Advantage plan. If you deposit back to the plan. Contact the plan at
are enrolled in a Medical Savings Account 1-800-823-9633 (TDD 711) for additional
plan, you can enroll in any stand-alone information.
prescription drug plan.
Geisinger Gold Medicare Advantage 22Talk to us about the many options
available to you.
Geisinger Gold Sales Counselors are offering free consultations
without any obligation. Call us today, and we can help you enroll
right over the phone! For your convenience, online enrollment is
also available at GeisingerGold.com.
To Find Out More …
Call 1-800-823-9633 today!
TDD: 711
8 a.m. to 8 p.m., (7 days a week, Oct . 1 - Feb. 14)
8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30)
GeisingerGold.com
100 N. Academy Avenue • Danville, PA 17822-3240
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