Metro Denver/Boulder Gold Plan + Rx (Cost) Coverage
Gold Plan + Rx (Cost) – $250.30/month
Gold Plan (Cost)* – $156.00/month
* Medical Only plans do not include the Part D prescription drug plan benefit.
Benefits May Include:
View plan details below for more information.
- Medicare Part D Prescription Drug Coverage
- Annual routine physical exam
- Vision screening
- Emergency and urgent care (Worldwide)
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Medicare Covered Benefit
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Gold Plan + Rx (Cost)
You Pay
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Monthly Health Plan Premium
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Medical
Prescription Drug
Total
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$156.00
$94.30
$250.30
* plus you must continue to pay Medicare Part B premium
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Primary Care Physician
Office Visit Copayment
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$15 per visit
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Specialist Care Physician
Office Visit Copayment
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$35 per visit
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Inpatient Hospital Copayment
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$450 per admission
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Outpatient Surgery
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$250 per visit
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Ambulance
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$100 per trip
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Emergency Room
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$50 per visit Worldwide
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Urgent Care
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$35 per visit Worldwide
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Part D Prescription Drug Benefit
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No deductible
$8.50 copay generic
$38 copay preferred brand
$58 copay nonpreferred brand
33% specialty
After $2,830 in retail drug expenses you pay $8.50 copay for generic drugs on Tier 1 only and 100% of cost for all other drugs until you reach $4,550 out of pocket drug costs
Beneficiary pays
$2.50 copay generic;
$6.30 copay for all other drugs; OR 5% (whichever is higher)
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Annual Routine Physical Exam
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$0
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Preventive Screening Services
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$0
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Skilled Nursing Facility
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$0 days 1-14
$95 days 15-100
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Durable Medical Equipment
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20%
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Please refer to the
Plan Highlights Grid for a comparison listing of all Medicare covered services and plan benefits for the Metro Denver/Boulder area.
Formulary
Click here to see the comprehensive list of prescription drugs covered on the Gold Plan + Rx (Cost) that includes Part D coverage.
Gold Plan (Cost) Extras May Include:
The products and services described as extras are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the RMHP grievance process.
- Prescription drug discount
- Vision discount program
- Hearing discount program
- Discounts on complementary care, for example: chiropractic and massage therapy
- Silver&Fit Affinity walking program to support wellness
- Optional dental plan
Click here for detailed information on the
Extras offered through the Medicare Plans.
Information is current as of 12/28/09. Please call to confirm you have the most up to date information about our Medicare Plans. Click here for a full list of Medicare Disclaimers.
CMS122809 S5860_H0602_1037014 MC150WEB