Geisinger Gold Preferred Advantage Rx (PPO)
H3924 - 059 - 22
(4 / 5)
Geisinger Gold Preferred Advantage Rx (PPO) is a Medicare Advantage (Part C) Plan by Geisinger Gold.
This page features plan details for 2024 Geisinger Gold Preferred Advantage Rx (PPO) H3924 – 059 – 22 available in South & East Pennsylvania.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Geisinger Gold Preferred Advantage Rx (PPO) is offered in the following locations.
Plan Overview
Geisinger Gold Preferred Advantage Rx (PPO) offers the following coverage and cost-sharing.
| Insurer: | Geisinger Gold |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,000 In and Out-of-network $4,000 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Geisinger Gold Preferred Advantage Rx (PPO) ?
Premium Breakdown
Geisinger Gold Preferred Advantage Rx (PPO) has a monthly premium of $79.00. 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 |
|---|---|---|---|---|
| $174.70 | $27.10 | $51.90 | $0.00 | $253.70 |
- 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 Advantage 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: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional 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 Full |
|---|---|
| $51.90 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $3.00 copay | $0.00 copay | ||
| 2 (Generic) | $20.00 copay | $0.00 copay | ||
| 3 (Preferred Brand) | $47.00 copay | $47.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | ||
| 6 (Vaccines ($0 cost sharing)) | $0.00 copay | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Vaccines ($0 cost sharing)) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $7.50 copay | $0.00 copay | ||
| 2 (Generic) | $50.00 copay | $0.00 copay | ||
| 3 (Preferred Brand) | $117.50 copay | $70.50 copay | ||
| 4 (Non-Preferred Drug) | $250.00 copay | $150.00 copay | ||
| 5 (Specialty Tier) | ||||
| 6 (Vaccines ($0 cost sharing)) | $0.00 copay | $0.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $3.00 copay | $0.00 copay | ||
| 6 (Vaccines ($0 cost sharing)) | $0.00 copay | $0.00 copay | ||
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $7.50 copay | $0.00 copay | ||
| 6 (Vaccines ($0 cost sharing)) | $0.00 copay | $0.00 copay | ||
| Generic drugs | ||||
| Brand-name drugs |
| 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 $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
Geisinger Gold Preferred Advantage Rx (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $4,000 In and Out-of-network $4,000 In-network |
| Yes |
| In-network | No |
| In-network | $0-250 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $0-250 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $25 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $15 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $15 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $15 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $15 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $30-275 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $30-275 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $30-275 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Cleaning | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Routine eye exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network | $200 copay (Not applicable.) (Not applicable.) |
| out-of-network | $200 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Routine foot care | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | $35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | $35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | $35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $200 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | $200 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $200 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $200 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $5-10 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $10 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $5-10 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $5-10 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $10 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $5-10 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $160 per day for days 21 through 45 $0 per day for days 46 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 20 $160 per day for days 21 through 45 $0 per day for days 46 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $38.00 |
| Deductible | nan |
Optional Benefits
Package #1
| Wellness programs (e.g., fitness, nursing hotline): | Monthly Premium: | $38.00 |
| Wellness programs (e.g., fitness, nursing hotline): | Deductible: | N/A |
| Preventive dental: | Monthly Premium: | $38.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $38.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eye exams: | Monthly Premium: | $38.00 |
| Eye exams: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $38.00 |
| Eyewear: | Deductible: | N/A |
| Hearing exam: | Monthly Premium: | $38.00 |
| Hearing exam: | Deductible: | N/A |
| Hearing aids: | Monthly Premium: | $38.00 |
| Hearing aids: | Deductible: | N/A |
Ready to sign up for Geisinger Gold Preferred Advantage Rx (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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