Geisinger Gold Classic Essential Rx (HMO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Geisinger Gold
- Rx
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $30 copay
Out-of-network: $0 copay
Emergency Room
$115 copay
Ambulance Coverage
In-network: $200 copay
Out-of-network: $200 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0 copay
Out-of-network: $0 copay
Lab services:
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$235 copay
Out-of-network: $0-$235 copay
Outpatient x-rays:
In-network: $30 copay
Out-of-network: $30 copay
Hospital Services
Inpatient hospital coverage:
Tier 1
$225 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Outpatient hospital coverage:
In-network: $0-$250 copay
Out-of-network: $0-$250 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $35 copay
Out-of-network: $35 copay
Urgent Care Coverage
$115 copay
Skilled Nursing Facility (SNF)
Tier 1
$0 per day for days 1-20
$160 per day for days 21-63
$0 per day for days 64-100
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $5 copay
Out-of-network: $5 copay
Outpatient individual therapy with a psychiatrist:
In-network: $10 copay
Out-of-network: $10 copay
Outpatient group therapy visits:
In-network: $5 copay
Out-of-network: $5 copay
Outpatient individual therapy visit:
In-network: $10 copay
Out-of-network: $10 copay
Dental, Vision, Hearing Benefits
Hearing Benefits
Hearing exam:
In-network: $20 copay
Out-of-network: $20 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$2.00 copay (30-day supply)
$5.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$50.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
25% coinsurance (30-day supply)
25% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
Ready to Enroll Online?
Or call and get free advice from licensed insurance agents
Looking for other plans in your area?