Gold Circle (HMO-POS C-SNP) is a Medicare Advantage Special Needs Plan by Gold Kidney Health Plan.
This page features plan details for 2024 Gold Circle (HMO-POS C-SNP) H4869 – 010 – 0.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Gold Circle (HMO-POS C-SNP) is offered in the following locations.
Gold Circle (HMO-POS C-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Chronic or Disabling Condition |
| Conditions Covered: | Cardiovascular Disorders, Chronic Heart Failure and Diabetes |
| Insurer: | Gold Kidney Health Plan |
| Health Plan Deductible: | Coming soon |
| MOOP: | $8,850 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Gold Circle (HMO-POS C-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $0.00 | $ |
Gold Circle (HMO-POS C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Basic |
| Additional Gap Coverage: | No |
| Formulary Link: | Formulary Link |
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 |
|---|---|
| $0.00 | $0.00 |
After you pay your $545.00 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.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
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.
Gold Circle (HMO-POS C-SNP) also provides the following benefits.
| Coming soon |
| In-network | Yes |
| $8,850 In-network |
| No |
| In-network | No |
| In-network | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | 20% coinsurance per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | 20% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | 20% coinsurance per visit (Authorization is not required.) (Referral is required.) |
| out-of-network Specialist | 20% coinsurance per visit (Authorization is not required.) (Referral is 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 | 20% coinsurance per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | 20% coinsurance per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| out-of-network Diagnostic tests and procedures | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| In-network Lab services | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| out-of-network Lab services | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| In-network Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is required.) |
| In-network Outpatient x-rays | 20% coinsurance (Authorization is required.) (Referral is required.) |
| out-of-network Outpatient x-rays | 20% coinsurance (Authorization is required.) (Referral is required.) |
| In-network Hearing exam | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 20% coinsurance (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 | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| out-of-network Physical therapy and speech and language therapy visit | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| In-network | 20% coinsurance (Not applicable.) (Not applicable.) |
| out-of-network | 20% coinsurance (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| 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 | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| out-of-network Diabetes supplies | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| 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 | $35 copay (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 | Coming soon (Authorization is required.) (Referral is not required.) |
| out-of-network | Coming soon (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | Coming soon (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | Coming soon (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| In-network Outpatient group therapy visit | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient group therapy visit | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| In-network Outpatient individual therapy visit | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| out-of-network Outpatient individual therapy visit | 20% coinsurance (Authorization is not required.) (Referral is required.) |
| In-network | Coming soon (Authorization is required.) (Referral is not required.) |
| out-of-network | Coming soon (Authorization is required.) (Referral is not required.) |
Ready to sign up for Gold Circle (HMO-POS C-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST