2019 MediGold Plan Options in Your Area

MediGold Plans Remove Option MediGold Southwest OH Classic Preferred (HMO) Remove Option MediGold Southwest OH Essential Care (HMO) Remove Option MediGold Medical Only (HMO)
Plan Premiums $120 monthly premium $0 monthly premium $60 monthly premium
PlansBest Match? Enroll View Details Enroll View Details Enroll View Details
Medical Deductible $0 $0 $0
Out-of-Pocket Maximum $3,900 $4,900 $3,900
Medical Benefits You pay: You pay: You pay:
Family Doctor Visits $0 $10 $0
Specialty Doctor Visits $45 $50 $30
Over-the-counter allowance $15 per month Not currently available with this plan $15 per month
Acupuncture $20 per visit, 6 per year Not currently available with this plan $20 per visit, 6 per year
Inpatient Hospital Visit $190 per day 1-4, $0 after day 4 $285 per day 1-7,
$0 after day 7
$75 per day 1-7, $0 after day 7
Outpatient Surgery $125 $275 $125
Hearing Aids $499/ear for Advanced
$799/ear for Premium
$699/ear for Advanced
$999/ear for Premium
$699/ear for Advanced
$999/ear for Premium
SilverSneakers Fitness $0 $0 $0
Urgent Care (Worldwide!) $40 (within the U.S.)
$90 (outside the U.S.)
$50 (within the U.S.)
$90 (outside the U.S.)
$40 (within the U.S.)
$90 (outside the U.S.)
Emergency Care (Worldwide!) $90 $90 $90
Optional Supplemental Dental $16 premium for comprehensive dental services $16 premium for comprehensive dental services $16 premium for comprehensive dental services
Preventive Dental $0 (with expanded network!) $0 (with expanded network!) $0 (with expanded network!)
Lab Test $0 $10 $0
Basic X-ray $20 $50 $30
MRI and other advanced imaging $50 $150 $70
Routine Eye Exam $0, 1 per year $0, 1 per year $0, 1 per year
Routine Hearing Exam $0, 1 per year $0, 1 per year $0, 1 per year
Durable Medical Equipment 20% 20% 20%
Observation $0 $0 $0
Part D Drug Benefits — Extra savings available at mail. Ask for details. Included! Included! This plan does not include Part D drug benefits.
Part D Deductible $0 $150, Tiers 3 - 5 Not applicable
Generic Viagra $15, 4 pills per month Not currently available with this plan Not applicable
Tier 1 90 day at mail order $0 $4 Not applicable
Tier 2 90 day at mail order $0 $36 Not applicable
Tier 3 90 day at mail order $90 $90 Not applicable
Tier 4 90 day at mail order $150 $190 Not applicable
Tier 5 90 day at mail order Not applicable Not applicable Not applicable
Tier 1 30 day retail $0 $2 Not applicable
Tier 2 30 day retail $15 $18 Not applicable
Tier 3 30 day retail $45 $45 Not applicable
Tier 4 30 day retail $75 $95 Not applicable
Tier 5 30 day retail 33% 30% Not applicable

MediGold is available to residents living in: Adams, Brown, Butler, Champaign, Clark, Clermont, Clinton, Delaware, Fairfield, Fayette, Franklin, Greene, Hamilton, Highland, Knox, Licking, Madison, Miami, Monroe, Montgomery, Morgan, Noble, Perry, Pickaway, Pike, Preble, Ross, Union, Warren and Washington counties, Ohio. Plans and premiums may vary by county. This chart is not a complete list of benefits. For more detailed information about our plan options, view the Summary of Benefits.

Out-of-network/non-contracted providers are under no obligation to treat MediGold members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

You may receive prescription drugs at home using our network mail order program, generally within 10 calendar days of when your order is received. For questions about mail order medication, call 1-866-785-5714 option 4 (TTY 711). Our mail order pharmacy is to obtain consent prior to shipping or delivering any prescriptions that the beneficiary did not personally initiate, unless the perscriber has initiated other mail order prescriptions for the beneficiary in the last 12 months.

Updated 10/2018