Geisinger Gold Preferred 360 Rx (PPO)

H3924 - 066 - 0
4.5 out of 5 stars (4.5 / 5)

Geisinger Gold Preferred 360 Rx (PPO) is a Medicare Advantage (Part C) Plan by Geisinger Gold.

This page features plan details for 2023 Geisinger Gold Preferred 360 Rx (PPO) H3924 – 066 – 0 available in Pennsylvania.

IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.

Locations

Geisinger Gold Preferred 360 Rx (PPO) is offered in the following locations.

Plan Overview

Geisinger Gold Preferred 360 Rx (PPO) offers the following coverage and cost-sharing.

Insurer:Geisinger Gold
Health Plan Deductible:$0.00
MOOP:$7,550 In and Out-of-network
$7,550 In-network
Drugs Covered:Yes

Ready to sign up for Geisinger Gold Preferred 360 Rx (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Premium Breakdown

Geisinger Gold Preferred 360 Rx (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$164.90 $0.00 $0.00 $0.00 $164.90
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Geisinger Gold Preferred 360 Rx (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Initial Coverage Limit: $4,660.00
Catastrophic Coverage Limit: $7,400.00
Drug Benefit Type: Enhanced
Gap Coverage: Yes
Formulary Link: Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.
Part D LIS 25% LIS 50% LIS 75% LIS Full
$0.00 $43.40 $34.80 $26.30 $17.70

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Drug TypeCost Share
Generic drugs$4.15 copay or 5% (whichever costs more)
Brand-name drugs$10.35 copay or 5% (whichever costs more)

Additional Benefits

Geisinger Gold Preferred 360 Rx (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-Network: No

Dental (comprehensive)

Diagnostic services: Not covered (no limits)
Endodontics:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Endodontics:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Extractions:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Extractions:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Non-routine services: Not covered (no limits)
Periodontics:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Periodontics:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Restorative services:In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Restorative services:Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required)

Dental (preventive)

Cleaning:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Cleaning:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Dental x-ray(s):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Dental x-ray(s):Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Fluoride treatment: Not covered (no limits)
Oral exam:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Oral exam:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI):In-Network: $35-280 copay (authorization required) (referral not required)
Diagnostic radiology services (e.g., MRI):Out-of-Network: $35-280 copay (authorization required) (referral not required)
Diagnostic tests and procedures:In-Network: $20 copay (authorization required) (referral not required)
Diagnostic tests and procedures:Out-of-Network: $20 copay (authorization required) (referral not required)
Lab services:In-Network: $20 copay (authorization required) (referral not required)
Lab services:Out-of-Network: $20 copay (authorization required) (referral not required)
Outpatient x-rays:In-Network: $35 copay (authorization required) (referral not required)
Outpatient x-rays:Out-of-Network: $35 copay (authorization required) (referral not required)

Doctor visits

Primary:In-Network: $5 copay per visit
Primary:Out-of-Network: $5 copay per visit
Specialist:In-Network: $35 copay per visit (authorization not required) (referral not required)
Specialist:Out-of-Network: $35 copay per visit (authorization not required) (referral not required)

Emergency care/Urgent care

Emergency: $95 copay per visit (always covered)
Urgent care: $35 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment:In-Network: $35 copay (authorization not required) (referral not required)
Foot exams and treatment:Out-of-Network: $35 copay (authorization not required) (referral not required)
Routine foot care:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Routine foot care:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)

Ground ambulance

In-Network: $275 copay
Out-of-Network: $275 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

Fitting/evaluation: Not covered (no limits)
Hearing aids – inner ear: Not covered (no limits)
Hearing aids – outer ear: Not covered (no limits)
Hearing aids – over the ear: Not covered (no limits)
Hearing exam:In-Network: $35 copay (authorization not required) (referral not required)
Hearing exam:Out-of-Network: $35 copay (authorization not required) (referral not required)

Hospital coverage (inpatient)

In-Network: $175 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required) (referral not required)
Out-of-Network: $175 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required) (referral not required)

Hospital coverage (outpatient)

In-Network: $0-350 copay per visit (authorization required) (referral not required)
Out-of-Network: $0-350 copay per visit (authorization required) (referral not required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$7,550 In and Out-of-network
$7,550 In-network

Medical equipment/supplies

Diabetes supplies:In-Network: 0-20% coinsurance per item (authorization required)
Diabetes supplies:Out-of-Network: 0-20% coinsurance per item (authorization required)
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: 20% 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: 20% coinsurance per item (authorization required)

Medicare Part B drugs

Chemotherapy:In-Network: 20% coinsurance (authorization required)
Chemotherapy:Out-of-Network: 5-20% coinsurance (authorization required)
Other Part B drugs:In-Network: 5-20% coinsurance (authorization required)
Other Part B drugs:Out-of-Network: 5-20% coinsurance (authorization required)

Mental health services

Inpatient hospital – psychiatric:In-Network: $175 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required) (referral not required)
Inpatient hospital – psychiatric:Out-of-Network: $175 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required) (referral not required)
Outpatient group therapy visit:In-Network: $5 copay (authorization required) (referral not required)
Outpatient group therapy visit:Out-of-Network: $5-10 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:In-Network: $5 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:Out-of-Network: $5-10 copay (authorization required) (referral not required)
Outpatient individual therapy visit:In-Network: $10 copay (authorization required) (referral not required)
Outpatient individual therapy visit:Out-of-Network: $5-10 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:In-Network: $10 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:Out-of-Network: $5-10 copay (authorization required) (referral not required)

Optional supplemental benefits

No

Preventive care

In-Network: $0 copay (authorization not required) (referral not required)
Out-of-Network: $0 copay (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit:In-Network: $35 copay (authorization required) (referral not required)
Occupational therapy visit:Out-of-Network: $35 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:In-Network: $35 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:Out-of-Network: $35 copay (authorization required) (referral not required)

Skilled Nursing Facility

In-Network: $0 per day for days 1 through 20
$160 per day for days 21 through 68
$0 per day for days 69 through 100 (authorization required) (referral not required)
Out-of-Network: $0 per day for days 1 through 20
$160 per day for days 21 through 68
$0 per day for days 69 through 100 (authorization required) (referral not required)

Transportation

Not covered

Vision

Contact lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Contact lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses):Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Other: Not covered (no limits)
Routine eye exam:In-Network: $20 copay (limits may apply) (authorization not required) (referral not required)
Routine eye exam:Out-of-Network: $20 copay (limits may apply) (authorization not required) (referral not required)
Upgrades: Not covered

Wellness programs (e.g., fitness, nursing hotline)

Covered (authorization not required) (referral not required)

Ready to sign up for Geisinger Gold Preferred 360 Rx (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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