Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.

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Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.
Your Guide to

Geisinger Gold
We’ll help you choose the Medicare
Advantage Plan that’s right for you.

                 APB_PA_CORE_2015
                 Y0032_H8468_14202_3
                 CMS Approved 8/11/14
Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.
We’ll help you every step of the way.
If you want to lower your health care expenses, look no further than
Geisinger Gold. We make it easy for you to get the affordable health
care protection you need.
You can speak with a Geisinger Gold Sales Counselor who understands
your concerns, listens to your needs, and gives you the kind of
straightforward information you need to make the best decision.
There’s no obligation. Call us today, and we can help you enroll right
over the phone! For your convenience, you can also enroll online at
GeisingerGold.com.

To Find Out More …
Call 1-800-823-9633 today!
TDD: 711
8 a.m. to 8 p.m., (7 days a week, Oct 1. - Feb. 14)
8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30)
GeisingerGold.com

Cover Photo: tecmc/iStock/Thinkstock
Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.
Table of Contents
What makes Geisinger Gold a smart choice for me? .................................................4
Get more for your money ...........................................................................................5
Choosing the best plan for you ..................................................................................6
Medicare Advantage Plan Overview ..........................................................................7-8
What is a Medicare Advantage plan?.........................................................................9
Are prescription drugs covered? ................................................................................9
What if I spend time outside the Geisinger Gold service area? ................................9
Are my doctors in the network? ................................................................................9
Who is eligible? .........................................................................................................9
When can I enroll? .....................................................................................................9
Do I qualify for a low income subsidy? .....................................................................10
How do I enroll? ........................................................................................................10
When will my coverage become effective? ...............................................................10
What if I change my mind?........................................................................................10
Here’s what you’ll pay with Geisinger Gold Medicare
Prescription Drug Coverage (Part D) .........................................................................11-12
Medicare Advantage Benefits Overview....................................................................13-18
Geisinger Gold Health+ Benefits ...............................................................................19
2015 Medicare Advantage Premiums ........................................................................20
What else should I know about Medicare Advantage plans?.....................................22
Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.
BananaStock/BananaStock/Thinkstock

                            To Find Out More …
                      Call 1-800-823-9633 today!
                               TDD: 711
           8 a.m. to 8 p.m., (7 days a week, Oct. 1. - Feb. 14)
            8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30)
                             GeisingerGold.com
Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.
What makes Geisinger Gold a smart choice for me?

       Geisinger Gold is the #1 ranked Medicare
       Advantage plan in Pennsylvania, and one
       of the top ten in the nation.*

                            Begun in 1994, Geisinger Gold serves more than 79,000 members.
                            Geisinger Gold has held the highest accreditation level from the
                            National Committee for Quality Assurance (NCQA) since 2006.

                                        Dedicated to Better Health

                                        “Providing quality health care coverage at
                                        affordable costs is Geisinger Gold’s primary mission.
                                        For nearly 20 years, we’ve been dedicated to
                                        working with physicians and hospitals to provide
                                        superior health care coverage to the residents
                                        in the counties we serve. Our position as the #1
                                        ranked Medicare Advantage plan in Pennsylvania
                                        and one of the top ten in the nation* is proof of
                                        our dedication to our members.”

                                                    Steven R. Youso
                                                    President and CEO
                                                    Geisinger Health Plan

 *NCQA’s Medicare Health Insurance Plan Rankings 2013-2014.
 For more information about the rankings, please visit
 http://www.ncqa.org/Directories/HealthPlans/HealthInsurancePlanRankings/
 MedicaidandMedicareHealthPlanRankings201314.aspx

                                                          Geisinger Gold Medicare Advantage 4
Geisinger Gold Your Guide to - We'll help you choose the Medicare Advantage Plan that's right for you.
Get more for your money.
      When you join a Geisinger Gold Medicare Advantage plan, you continue to get all of your
      Medicare Part A & B benefits. Geisinger Gold Medicare Advantage plans also include a wide
      range of cost-saving features and wellness programs not available with Medicare Parts A and
      B.

                                                                           Geisinger Gold
                                     Medicare Parts A and B
                                                                      Medicare Advantage plans

                                                                     Plans starting at $0 a month; you
                                   You must pay your
     Low Cost                                                        must continue to pay your Part B
                                   Part B premium
                                                                     premium.

                                                                    Prescription drug coverage with
     Prescription Drug             No                               generic drug copays as low as $3
                                                                    is available.

                                                                    Yes: Most plans have an annual
     Out-of-Pocket Protection      No                               limit on how much you pay in
                                                                    deductibles and copays.

                                                                    Included with some plans, optional
     Routine Dental Services       No
                                                                    with others.
                                                                    Included with some plans, optional
     Hearing Aid Benefit           No
                                                                    with others.
     Routine Vision/ Eyewear                                        Included with some plans, optional
                                   No
     Benefits                                                       with others.
                                                                    Included with some plans, optional
     Fitness Benefits              No
                                                                    with others.

     Care Management
     Programs for heart                                             Yes, with our Classic (HMO),
     conditions, diabetes, blood   No                               Preferred (PPO) and
     pressure, kidney disease                                       Secure (HMO SNP) plans.
     and much, much, more!

     Coverage of preventive                                         Services covered with $0 copay
     services, including certain                                    for all Geisinger Gold plans
                                   Yes
     health screenings and                                          (For Reserve (MSA) plan,
     immunizations                                                  deductible must be met).

5 Geisinger Gold Medicare Advantage
Choosing the best plan for you
Geisinger Gold offers a wide-array of health plans which include: traditional HMO, Preferred
Provider Organization (PPO), Special Needs Plans, and Medical Savings Account (MSA).
While each of the plans we offer will provide you with outstanding health care coverage, finding
the right plan for you is too important to leave to guesswork. That’s why Geisinger Gold Sales
Counselors provide expertise and guidance that makes it easy for you to get the affordable health
coverage you want. In fact, we can walk you through the entire process … answering all your
questions and helping you enroll in a plan that fits both your needs and budget.
Geisinger Gold offers a variety of choices. To get started, think about what’s important to you.
If you want a plan that’s easy on the budget, consider one of our Medicare Advantage HMO
or PPO plans. They offer broad coverage, low out-of-pocket costs and a provider network that
includes over 29,000 providers and over 90 hospitals.
If you have full Medicaid benefits in addition to Medicare, our Special Needs Plan, Secure Rx,
may be right for you.
If flexibility is important to you, consider our Reserve (MSA) plan. It offers the freedom to
choose any doctor or hospital, anywhere in the U.S., that accepts Medicare and agrees to see you.

Jupiterimages/Stockbyte/Thinkstock

                                                              Geisinger Gold Medicare Advantage 6
Medicare Advantage Plan Overview
Geisinger Gold Classic (HMO) plans                     Geisinger Gold Preferred (PPO) plans
Geisinger Gold Classic (HMO) plans are HMO             Geisinger Gold Preferred (PPO) is a PPO plan that
plans that offer more comprehensive protection         offers predictable costs and the freedom to choose
and lower out-of-pocket costs than you get with        any doctor or hospital you wish. No Primary Care
Original Medicare. A Primary Care Physician            Physician selection or referrals are needed. You
works to coordinate your medical care. Covered         can use any provider who is part of our network,
services including hospitalization, routine office     and you have the flexibility to use out-of-network
visits, physicals, immunizations, diagnostic tests     providers at a higher out-of-pocket cost.
and x-rays, are covered with affordable, predictable
costs.

Geisinger Gold Secure
(HMO SNP) plan
Geisinger Gold Secure (HMO SNP) is a Special
Needs HMO plan for individuals who meet certain
income or need-based criteria. If you are fully
eligible for both Medicare and Medicaid this plan
may be right for you. Prescription drug coverage
is included.

       Wavebreakmedia Ltd/Wavebreak Media/Thinkstock

7 Geisinger Gold Medicare Advantage
Geisinger Gold Reserve (MSA) plan
Available statewide, this Medicare Advantage Plan option puts you in control of your health care dollars. It
combines a high-deductible insurance plan with a savings account to pay your medical bills. There’s no
monthly premium and you have the freedom to choose any medical professional who accepts Medicare and
agrees to see you. Here’s how it works:
Geisinger Gold deposits $1,020 a year (provided by Medicare) into your Medical Savings Account to help pay
qualified medical expenses such as doctor visits, diagnostics tests such as X-rays, inpatient hospital stays, etc.
This $1,020 can help meet your annual $3,600 deductible. Once the deductible is met, Geisinger Gold pays
all Medicare covered expenses in full. Any money left in your Medical Savings Account at the end of the
calendar year rolls over to the next year.
Example 1: Over time, your MSA account can pay for plan-covered expenses, resulting in no cost to you. You
can use the funds deposited to your MSA account first to pay for medical expenses. If you do not use all the
money in your MSA account, that money carries over to the next year, and is added to your annual deposit.
The funds in your MSA account can build over time to meet your full annual deductible.
                $3,600 Annual Deductible - Geisinger Gold Pays Costs After Deductible is Met

                                                                              Account
                                                                              Balance
                                         Account                               (Carry     Medical
                                         Balance                               Over+       Costs
     Account
                                          (Carry                  Balance     Deposit)      Paid
     Balance
    (Deposit)                            Over +                    Carry                  by MSA
                 Medical
                             Balance     Deposit)    Medical       Over       $1,760      Account     Balance
                  Costs
                              Carry                   Costs       to New                               Carry
     $1,020        Paid
                              Over        $1,540       Paid         Year                      $900     Over
                 by MSA
                             to New                  by MSA                                           to New
                 Account
                               Year                  Account       $740                                 Year
                   $500
                               $520                    $800                                             $860

                 Year 1                              Year 2                             Year 3
  In each year, medical costs are less than the MSA account balance, resulting in no cost to you, and a higher
                                starting balance each new year due to carry over.

Example 2: Plan-Covered Expenses Exceed the Deductible

                                                                                     $6,400
                           For the year, your
                           medical costs total                        $2,580
                                $10,000                              (to meet
                                                        $1,020
                                                                      $3,600
                                                                    deductible)

                                                        MSA             You         Geisinger
                                                       Account          Pay          Gold
                                                        Pays                          Pays

                                                                       Geisinger Gold Medicare Advantage             8
Geisinger Gold Medicare Advantage
      Answers to frequently asked questions

      What is a Medicare Advantage                       Are my doctors in the network?
      plan?                                              Visit GeisingerGold.com for the most up-to­
      Medicare Advantage plans were created to           date information about our network. There
      give Medicare recipients greater benefits          you will find information about the Health
      than original Medicare (Medicare Parts A           Plan’s participating primary care physicians,
      & B) alone. They follow guidelines set by          specialists, mental health providers, hospitals
      Medicare, but may offer a wide variety of          and other services, including durable medical
      additional benefits and plan options. When         equipment vendors, radiology facilities and
      you’re insured with a Medicare Advantage           more. You can also call a Geisinger Gold Sales
      plan, you still have Medicare. But your            Counselor who will help you find a doctor and
      coverage is administered by a private company,     answer any questions you may have.
      rather than by the government. So instead of
      presenting your Medicare Card for services,        Who is eligible?
      you’ll use your Medicare Advantage Card.           You are eligible to join a Geisinger Gold
                                                         Medicare Advantage plan as long as you have
      Are prescription drugs covered?                    Medicare Parts A and B; live in the health
      Yes! With Geisinger Gold, you can get all your     plan’s service area; and do not have End-Stage
      coverage from a single source, with generic        Renal Disease (ESRD). If you are interested
      drug copays as low as $3.                          in Geisinger Gold Reserve (MSA), additional
                                                         restrictions may apply.
      You may be able to get extra help to pay for
      your prescription drug premiums and costs. To      When can I enroll?
      see if you qualify for getting extra help, call:
      1-800-MEDICARE (1-800-633-4227). TTY/              Medicare beneficiaries can enroll for Geisinger
      TDD users should call 1-877-486-2048, 24           Gold Medicare Advantage coverage at certain
      hours a day/7 days a week; The Social Security     times of the year.
      Administration at 1-800-772-1213 between           Annual Election Period - Oct. 15 - Dec. 7
      7:00 a.m. and 7:00 p.m., Monday through
      Friday. TTY/TDD users should call 1-800­           You can enroll in or switch to a new Medicare
      325-0778; or your state Medicaid office.           Advantage plan or Medicare Advantage
                                                         prescription drug plan during the Annual
      What if I spend time outside the                   Election Period (AEP). For 2015 coverage, the
      Geisinger Gold service area?                       Annual Election Period is from October 15 to
                                                         December 7, 2014.
      Medical emergency services are covered
      worldwide under all of our HMO and PPO
      plans. Geisinger Gold Preferred (PPO) plans
      have in- and out-of-network coverage, with no
      referrals required. Your out-of-pocket expenses
      will be higher if you use providers who are not
      members of the network.
      Geisinger Gold Reserve (MSA) members can
      go to any medical professional that accepts
      Medicare and agrees to see them.

9 Geisinger Gold Medicare Advantage
Geisinger Gold Medicare Advantage
Answers to frequently asked questions

Initial Coverage Election Period                How do I enroll?
When you turn 65 (or when you retire) or        We make enrollment easy. During the
otherwise become eligible for Medicare, you     Annual Election Period for Medicare
qualify for an Initial Election Period. This    beneficiaries, you can talk to one of our
is usually a seven-month period that begins     local Geisinger Gold Sales Counselors
three months before your birthday month         for advice and assistance. Once you
the month of and 3 months after you are first   decide what plan is right for you, the Sales
eligible for both Medicare Part A and Part B.   Counselor can complete your enrollment
Beyond your Initial Election Period, certain    right over the phone! You can also visit
circumstances may make you eligible to          GeisingerGold.com for plan information
enroll for coverage at any time. Eligibility    and to enroll online. In-person enrollment
for these Special Election Periods include      meetings may also be available.
a change in residence, delayed retirement,
disability, loss of benefits if your existing   When will my coverage become
plan’s contract is not renewed by Medicare,     effective?
loss of low income subsidy or special needs     If you enroll between October 15 and
status. Please call for more information.       December 7, 2014, your coverage will
                                                become effective on January 1, 2015.
Do I qualify for a low income
subsidy?                                        What if I change my mind?
If you have limited resources and income,       Between January 1 and February 14, you
you may be eligible for a Low Income            can disenroll from a Medicare Advantage
Subsidy. This subsidy provides help with        plan and return to Original Medicare. As a
monthly premiums, annual deductibles,           result of this change, you would be eligible
and prescription drug copayments related        to enroll in a stand-alone Prescription Drug
to a Medicare prescription drug plan.           Plan (PDP). You will not be able to make
Incremental and full subsidies are awarded,     any further changes until the next Annual
based on income and asset testing using         Election Period (unless you qualify for a
federal guidelines. Low Income Subsidies        special election period during the year). The
are administered by the Social Security         annual disenrollment period does not apply
Administration and the Center for Medicare      for Geisinger Gold Reserve (MSA).
and Medicaid Services.

                                  To Find Out More …
                           Call 1-800-823-9633 today!
                                    TDD: 711
               8 a.m. to 8 p.m., (7 days a week, Oct. 1. - Feb. 14)
                8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15. - Sept. 30)
                               GeisingerGold.com

                                                         Geisinger Gold Medicare Advantage      10
Here’s what you’ll pay with
       Geisinger Gold Medicare Prescription
       Drug Coverage (Part D).

        Classic Complete Rx, Preferred Complete Rx, Preferred Essential Rx
        Annual Deductible: $0

        Initial Coverage

           Until total yearly drug costs reach $2,960, a member pays:
            Retail Tier 1: $6 copay for 1 month (30 day) supply, $18 copay for 3 month (90 day) supply
            Retail Tier 2: $20 copay for 1 month (30 day) supply, $60 copay for 3 month (90 day) supply
            Retail Tier 3: $39 copay for 1 month (30 day) supply, $117 copay for 3 month (90 day) supply
            Retail Tier 4: $85 copay for 1 month (30 day) supply, $255 copay for 3 month (90 day) supply
            Retail Tier 5: 33% coinsurance for one month (30 day) supply

        Classic Advantage Rx, Preferred Advantage Rx, Preferred Select Rx
        Annual Deductible: $0

        Initial Coverage

           Until total yearly drug costs reach $2,960, a member pays:
            Retail Tier 1: $3 copay for 1 month (30 day) supply, $9 copay for 3 month (90 day) supply
            Retail Tier 2: $18 copay for 1 month (30 day) supply, $54 copay for 3 month (90 day) supply
            Retail Tier 3: $39 copay for 1 month (30 day) supply, $117 copay for 3 month (90 day) supply
            Retail Tier 4: $85 copay for 1 month (30 day) supply, $255 copay for 3 month (90 day) supply
            Retail Tier 5: 33% coinsurance for one month (30 day) supply

11 Geisinger Gold Medicare Advantage
Coverage Gap (all plans)
After total yearly drug costs reach $2,960, but before a member’s yearly out-of-pocket reaches
$4,700, members enter the coverage gap. While in the gap, Geisinger Gold members still have
access to Tier 1 generic medications for as low as $3 (depending on your plan) for a 30-day
supply. For other medications, member pays 65% of the cost for the generic medications and
45% of the cost for brand medications. For example, you would pay $45 for a $100 brand-name
drug and $6.50 for a $10 generic version of that drug.

Catastrophic Coverage (all plans)
After yearly out-of-pocket drug costs reach $4,700, a member pays $2.65 copay for generic
(including brand drugs treated as generic) and $6.60 copay for all other drugs or 5% coinsurance,
whichever amount is greater.

Secure Rx
Annual Deductible: $0 annual deductible*
Depending on your level of Extra Help, you pay the following*:
For generic drugs (including brand drugs treated as generic), either:
- A $0 copay or
- A $1.20 copay or
- A $2.65 copay

For all other drugs, either:
- A $0 copay or
- A $3.60 copay or
- A $6.60 copay.

After your yearly out-of-pocket drug costs reach $4,700, you pay a $0 copay.*

*Note: Generally, members in Secure 1 will not be subject to a deductible or the coverage gap.
Members will pay low, predictable copays for their medications right away, depending on the
level of Extra Help they get from Medicare.

                                                               Geisinger Gold Medicare Advantage 12
Medicare Advantage Benefits Overview
 Medicare Advantage
 premiums are located                     Classic Advantage (HMO)           Classic Complete Rx (HMO)
 on page 20                                Member Responsibility              Member Responsibility
  Annual Medical Deductible          No Deductible                        No Deductible
  Annual Medical Out-of-Pocket       $3,400                               $6,700
  Maximum
  Inpatient Hospital Care            $125 days 1-5                        $190 days 1-7
                                     $0 days 6-90                         $0 days 8-90
  Skilled Nursing Facility Care      $40 days 1-20                        $0 days 1-20
                                     $75 days 21-54                       $156 days 21-63
                                     $0 days 55-100                       $0 days 64-100
                                     (no prior hospital stay required)    (no prior hospital stay required)
  Emergency Care/Urgent Care         $65/$20 (Waived if admitted)         $65/$35 (Waived if admitted)
  Primary Care/Specialty Care        $5/$20                               $10/$35
  Provider
  Outpatient Lab/Diagnostic Tests    $5/$5                                $5/$5
  Outpatient X-Rays                  $25                                  $30
  Outpatient MRI, CT, PET Scans      $100 per day                         20%
  Outpatient Ambulatory Surgery      20%                                  20%
  Ambulance Services (each way)      $100 (Waived if admitted)            $175 (Waived if admitted)
  Durable Medical Equipment          20%                                  20%
  Medicare Part D Prescription Drug Available (for additional cost)       Included
  Coverage
  Medicare-Covered Eyewear          $0                                    $0
  (Post-Cataract Surgery)           Only Medicare-covered (Basic          Only Medicare-covered (Basic
                                    frames and lenses)                    frames and lenses)
  Glaucoma screening (1 per year,    $0                                   $0
  office visit copay may apply)
  Dental Services (Preventive):      $20 for exam and cleaning every      Optional with this plan as part
  Exam, Cleaning, and X-Ray          six months; $20 bitewing only and    of the Health+ benefit package.
                                     $30 panoramic and other types        Please see page 19 for details.
                                     every year
  Routine Contact Lenses or          $200 maximum benefit every two       Optional with this plan as part
  Eyeglasses (Lenses and Frames)     years                                of the Health+ benefit package.
                                                                          Please see page 19 for details.
  Hearing Exams - Diagnostic         $20, one per year                     Optional with this plan as part
  Routine                                                                  of the Health+ benefit package.
                                                                           Please see page 19 for details.
  Hearing Aids/Fitting for Hearing   $800 maximum benefit every three Optional with this plan as part
  Aids                               years (fitting and evaluation includ­ of the Health+ benefit package.
                                     ed in this limit)                     Please see page 19 for details.
  Fitness Benefits                   $90 every three months to pay for Optional with this plan as part
                                     fitness center memberships or other of the Health+ benefit package.
                                     eligible fitness costs                Please see page 19 for details.

13 Geisinger Gold Medicare Advantage
Secure Rx (HMO SNP)*
                                                          Member Responsibility
Annual Medical Deductible                None to Member; Medicare Fee-for-Service Deductible billed to
                                         Medicaid
Annual Medical Out-of-Pocket             $6,700
Maximum
Inpatient Hospital Care                  $0

Skilled Nursing Facility Care            $0

Emergency Care/Urgent Care               $0

Primary Care/Specialty Care Provider     $0

Outpatient Lab/Diagnostic Tests          $0

Outpatient X-Rays                        $0

Outpatient MRI, CT, PET Scans            $0

Outpatient Ambulatory Surgery            $0

Ambulance Services (each way)            $0

Durable Medical Equipment                $0

Over the Counter Medications and         $50 allowance every 3 months
Supplies
Medicare Part D Prescription Drug        Included
Coverage
Medicare-Covered Eyewear                 $0
(Post-Cataract Surgery)
Glaucoma screening (1 per year, office   $0
visit copay may apply)
Dental Services (Preventive): Exam,      $0 for exam, cleaning and x-ray, every 6 months; Max. $2,000/
Cleaning, and X-Ray                      year combined for all non-Medicare dental; Incl. simple fillings,
                                         extractions and dentures
Routine Contact Lenses or Eyeglasses     $200 maximum benefit every year
(Lenses and Frames)
Hearing Exams - Diagnostic Routine       $0, one per year

Hearing Aids/Fitting for Hearing Aids    $600 maximum benefit every three years (fitting and evaluation
                                         included in this limit)
Fitness Benefits                         $90 every three months to pay for fitness center memberships or
                                         other eligible fitness costs
*Secure Rx (HMO SNP) premiums and costs based on Medicaid eligibility

                                                                 Geisinger Gold Medicare Advantage           14
Medicare Advantage Benefits Overview
 Medicare Advantage
 premiums are located                                   Preferred Advantage Rx (PPO)
 on page 20                                                Member Responsibility
                                                   In-Network               Out-of-Network
        Annual Medical Deductible
                                                              $0 In/Out Combined
        Annual Medical Out-of-Pocket    $6,700; In-network only           $10,000 in and out combined
        Maximum
        Inpatient Hospital Care         $390 per stay                     35%

        Skilled Nursing Facility Care   $0 days 1-20                      35%
                                        $156 days 21-63
                                        $0 days 64-100

        Emergency Care/Urgent Care      $65/$35 (Waived if admitted)

        Primary Care/Specialty Care     $10/$35                           35%/35%
        Provider

        Outpatient Lab/Diagnostic       $20/$20                           35%
        Tests

        Outpatient X-Rays               $20                               35%

        Outpatient MRI, CT, PET         20%                               35%
        Scans

        Outpatient Ambulatory Surgery 20%                                 35%

        Ambulance Services (each        $200 (Waived if admitted)         $200 (Waived if admitted)
        way)
        Durable Medical Equipment       20%                               20%

        Medicare-Covered Eyewear        $0                                $0 after deductible
        (Post-Cataract Surgery)         Only Medicare-covered (Basic      Only Medicare-covered
                                        frames and lenses)                (Basic frames and lenses)
        Glaucoma screening (1 per       $0                                $0
        year, office visit copay may
        apply)
        Medicare Part D Prescription    Included
        Drug Coverage

        Geisinger Gold Health+          Provides coverage for preventive dental services, routine vision
        Optional Benefits               and hearing care, and fitness center benefits. Please see page 19
                                        for details on this valuable benefits package.

15 Geisinger Gold Medicare Advantage
Preferred Complete Rx (PPO)
                                                  Member Responsibility
                                          In-Network              Out-of-Network
Annual Medical Deductible
                                                     $0 In/Out Combined
Annual Medical Out-of-Pocket $6,700; In-network only             $10,000 in and out combined
Maximum
Inpatient Hospital Care       $218 days 1-7                      45%
                              $0 days 8-90
Skilled Nursing Facility Care $0 days 1-20                       45%
                              $156 days 21-63
                              $0 days 64-100

Emergency Care/Urgent Care     $65/$40 (Waived if admitted)

Primary Care/Specialty Care    $10/$40                           45%
Provider

Outpatient Lab/Diagnostic      $25/$25                           45%
Tests

Outpatient X-Rays              $25                               45%

Outpatient MRI, CT, PET        30%                               45%
Scans

Outpatient Ambulatory          30%                               45%
Surgery
Ambulance Services (each       $190 (Waived if admitted)         $190 (Waived if admitted)
way)
Durable Medical Equipment      20%                               20%
Medicare-Covered Eyewear       $0                                $0 after deductible
(Post-Cataract Surgery)        Only Medicare-covered (Basic      Only Medicare-covered
                               frames and lenses)                (Basic frames and lenses)
Glaucoma screening (1 per      $0                                $0
year, office visit copay may
apply)
Medicare Part D Prescription   Included
Drug Coverage

Geisinger Gold Health+         Provides coverage for preventive dental services, routine vision
Optional Benefits              and hearing care, and fitness center benefits. Please see page 19
                               for details on this valuable benefits package.

                                                           Geisinger Gold Medicare Advantage 16
Medicare Advantage Benefits Overview
 Medicare Advantage
 premiums are located                                     Preferred Select Rx (PPO)
 on page 20                                                Member Responsibility
                                                   In-Network                Out-of-Network
        Annual Medical Deductible
                                                               $1,000 In/Out Combined
        Annual Medical Out-of-Pocket    $6,700; In-network only           $10,000 in and out combined
        Maximum
        Inpatient Hospital Care         $350 per stay after deductible    35% after deductible

        Skilled Nursing Facility Care   $0 days 1-20                      35% after deductible
                                        $156 days 21-57
                                        $0 days 58-100
                                        after deductible
        Emergency Care/Urgent Care      $65/$35 (Waived if admitted)

        Primary Care/Specialty Care     $10/$35                           35% after deductible
        Provider

        Outpatient Lab/Diagnostic       $20/$20 after deductible          35% after deductible
        Tests

        Outpatient X-Rays               $20 after deductible              35% after deductible

        Outpatient MRI, CT, PET         20% after deductible              35% after deductible
        Scans

        Outpatient Ambulatory Surgery $295 after deductible               35% after deductible

        Ambulance Services (each        $200 after deductible (Waived     $200 after deductible (Waived
        way)                            if admitted)                      if admitted)

        Durable Medical Equipment       20%                               20%

        Medicare-Covered Eyewear        $0                                $0 after deductible
        (Post-Cataract Surgery)         Only Medicare-covered (Basic      Only Medicare-covered
                                        frames and lenses)                (Basic frames and lenses)
        Glaucoma screening (1 per       $0                                $0
        year, office visit copay may
        apply)
        Medicare Part D Prescription    Included
        Drug Coverage

        Geisinger Gold Health+          Provides coverage for preventive dental services, routine vision
        Optional Benefits               and hearing care, and fitness center benefits. Please see page 19
                                        for details on this valuable benefits.

17 Geisinger Gold Medicare Advantage
Preferred Essential Rx (PPO)
                                                   Member Responsibility
                                           In-Network                 Out-of-Network
Annual Medical Deductible
                                                     $1,000 In/Out Combined
Annual Medical Out-of-Pocket    $6,700; In-network only           $10,000 in and out combined
Maximum
Inpatient Hospital Care         $218 days 1-7                     35% after deductible
                                $0 days 8-90
Skilled Nursing Facility Care   $0 days 1-20                      35% after deductible
                                $156 days 21-57
                                $0 days 58-100
                                after deductible
Emergency Care/Urgent Care      $65/$25 (Waived if admitted)

Primary Care/Specialty Care     $15/$35                           35% after deductible
Provider

Outpatient Lab/Diagnostic       $25/$25                           35% after deductible
Tests

Outpatient X-Rays               $45                               35% after deductible

Outpatient MRI, CT, PET         20% after deductible              35% after deductible
Scans

Outpatient Ambulatory Surgery 20% after deductible                35% after deductible

Ambulance Services (each way) $150 after deductible (Waived       35% after deductible (Waived if
                              if admitted)                        admitted)

Durable Medical Equipment       20%                               35% after deductible

Medicare-Covered Eyewear        $0                                $0 after deductible
(Post-Cataract Surgery)         Only Medicare-covered (Basic      Only Medicare-covered
                                frames and lenses)                (Basic frames and lenses)
Glaucoma screening (1 per       $0                                $0
year, office visit copay may
apply)
Medicare Part D Prescription    Included
Drug Coverage

Geisinger Gold Health+          Provides coverage for preventive dental services, routine vision
Optional Benefits               and hearing care, and fitness center benefits. Please see page 19
                                for details on this valuable benefits.

                                                           Geisinger Gold Medicare Advantage 18
Geisinger Gold Health+ Benefits

        Geisinger Gold is pleased to introduce Health+, a package of valuable benefits which are not
        covered by Medicare. This package is designed to complement your Medicare Advantage plan
        by providing coverage for routine dental services, vision services, hearing aids, and fitness ben-
        efits. Health+ gives you more flexibility to spend your health care dollars the way you want and
        need to, including the ability to join any fitness center you want!

         Dental Services (Preventive):     $250 every year to pay for:
         Exam, Cleaning, and X-Ray           1 cleaning every six months
                                             1 exam every six months
                                             1 x-ray every year
         Vision Exams - Diagnostic Routine $20 copay
         (1 per year)

         Routine Contact Lenses or             $100 benefit maximum every year
         Eyeglasses (Lenses and Frames)

         Hearing Exams - Diagnostic            $20 copay
         Routine (1 per year)

         Hearing Aids/Fitting for Hearing      $250 maximum benefit every year
         Aids                                  (includes fitting and evaluation)

         Fitness Benefits                      $90 reimbursement every three months
                                               to pay for fitness center activities such
                                               as memberships, classes, or training
                                               sessions

        These valuable benefits are included in Classic Advantage, Classic Advantage Rx and Secure
        Rx. They can be added to the following plans for an additional monthly cost of $38:
          • Classic Complete Rx
          • Preferred Advantage Rx
          • Preferred Complete Rx
          • Preferred Select Rx
          • Preferred Essential Rx
          • Reserve

       For more information on Geisinger Gold Medicare Advantage plans, please
       visit GeisingerGold.com or call us today at 1-800-823-9633. Some dental
       and vision services may be covered by Medicare. Call 1-800-823-9633 for details.

19 Geisinger Gold Medicare Advantage
2015 Medicare Advantage Monthly Premiums

                                                                                                Susquehanna
                                          otter
                                         Potter               Tioga
                                                                                                                   Wayne

                                                                                               Wyoming
                                                                                               Wyoming
                             ameron
                            Camer on                                             Sullivan                   Lacka
                                                                                                            Lack awanna
                                                                Lycoming                                                    Pike
                                                  Clinto
                                                  Clinton
        Jefferson                                                                               Luz
                                                                                                Luzerne
                                                                                  Columbia
                                                                                                                   Monroe
                                                                                                                    onroe
                    Clearfield                                                 Montour
                                                                                 ntour
                                             Cen
                                             Ce ntre                Union                               Carbon
                                                                          Northumberland
                                                                   Snyder Nor
                                                                   Sny        thumberland
                                                                                                                   Northampt
                                                                                                                   Nor thampton
                                                                                                                             on
                                                                                   Schuylkill
                                                                                    chuylkill
                 Cambria                           Mifflin                                                   Lehigh
                                                         Juniata            Dauphin
                           Blair                                                                    Berks
                                                              Perrr y
                                                              Pe
                                                                                     Lebanon
                                   Huntingdon
                                                         Cumberland
                                                                                       Lancaster
                                                                                       Lancast er

      Somerset
                                    ulton
                                   Fult on                                    Yor
                                                                              York
                                                              Adams

                                       Central               Northeast               South            Southeast              West
   Plan Name                           Region                 Region                 Region            Region               Region
   Classic Advantage                     $110                     $95                  $90                   $50              $100
   Classic Advantage Rx                  $149                    $139                 $124                  $119              $129

   Classic Complete Rx                       $0                    $0                  $0                    $0                $0

   Secure Rx*                                $0                    $0                  $0                    $0                $0

   Preferred Advantage Rx           Not Available           Not Available             $70                   $75           Not Available

   Preferred Complete Rx            Not Available           Not Available              $0                    $0           Not Available

   Preferred Select Rx                   $179                    $159           Not Available        Not Available            $119

   Preferred EssenƟal Rx** Not Available                    Not Available       Not Available               $31           Not Available
   Geisinger Gold Reserve (MSA) available in all PA counties with $0 monthly premium

   *Secure Rx (HMO SNP) premiums and costs based on Medicaid eligibility

   **Preferred Essential Rx available in Carbon, Lehigh and Northampton counties only

                                                                                         Geisinger Gold Medicare Advantage 20
FPO for image

         Fuse/Thinkstock

                                    To Find Out More …
                              Call 1-800-823-9633 today!
                                       TDD: 711
                     8 a.m. to 8 p.m., (7 days a week, Oct. 1. - Feb. 14)
                      8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30)
                                       GeisingerGold.com

21 Geisinger Gold Medicare Advantage
What else should I know about Medicare Advantage plans?

Geisinger Gold Medicare Advantage HMO,              MSA Plans combine a high deductible
PPO, HMO POS, HMO SNP and MSA plans                 Medicare Advantage Plan and a trust or
are offered by Geisinger Health Plan/Geisinger      custodial savings account (as defined and/or
Indemnity Insurance Company, health                 approved by the IRS). The plan deposits money
plans with a Medicare contract. Continued           from Medicare into the account. You can use
enrollment in Geisinger Gold depends on             this money to pay for your health care costs,
annual contract renewal.                            but only Medicare-covered expenses count
                                                    toward your deductible. The amount deposited
The benefit information provided is a brief         is usually less than your deductible amount, so
summary, not a complete description of              you generally have to pay out-of-pocket before
benefits. For more information contact the          your coverage begins.
plan. Limitations, copayments, and restrictions
may apply. Benefits, formulary, pharmacy            Medicare MSA Plans don’t cover prescription
network, premium and/or copayments/co­              drugs. If you join a Medicare MSA Plan,
insurance may change on January 1 of each           you can also join any separate Medicare
year. You must continue to pay your Medicare        Prescription Drug Plan.
Part B premium. Secure (HMO SNP) members
must meet certain eligibility requirements.         You must file Form 1040, US Individual
Secure 1 (HMO SNP) costs may vary based             Income Tax Return, along with Form 8853,
on the level of Extra Help you receive. Please      “Archer MSA and Long-Term Care Insurance
contact the plan for further details.               Contracts” with the Internal Revenue Service
                                                    (IRS) for any distributions made from your
A sales person will be present at meetings          Medicare MSA account to ensure you aren’t
with information and applications. For              taxed on your MSA account withdrawals. You
accommodation of persons with special needs         must file these tax forms for any year in which
at sales meetings call 1-800-823-9633 (TDD          an MSA account withdrawal is made, even if
users should call 711).                             you have no taxable income or other reason for
                                                    filing a Form 1040. MSA account withdrawals
Members must get their prescriptions from           for qualified medical expenses are tax free,
network pharmacies. In case of emergency,           while account withdrawals for non-medical
members may go to a non-network pharmacy.           expenses are subject to both income tax and a
You may only enroll in one prescription drug        fifty (50) percent tax penalty. Tax publications
plan at a time. If you are enrolled in a Medicare   are available on the IRS website at http://www.
Advantage plan which offers prescription drug       irs.gov or from 1-800-TAX-FORM
coverage, you must take your prescription drug      (1-800-829-3676).
coverage from that plan.
                                                    There are additional restrictions to join an
Prescription drug coverage from Geisinger           MSA plan, and enrollment is generally for
Gold is offered exclusively to Geisinger Gold       a full calendar year unless you meet certain
members. You cannot enroll in a standalone          exceptions. Those who disenroll during the
prescription drug plan, unless you disenroll        calendar year will owe a portion of the account
from your Medicare Advantage plan. If you           deposit back to the plan. Contact the plan at
are enrolled in a Medical Savings Account           1-800-823-9633 (TDD 711) for additional
plan, you can enroll in any stand-alone             information.
prescription drug plan.

                                                            Geisinger Gold Medicare Advantage 22
Talk to us about the many options
available to you.
Geisinger Gold Sales Counselors are offering free consultations
without any obligation. Call us today, and we can help you enroll
right over the phone! For your convenience, online enrollment is
also available at GeisingerGold.com.
To Find Out More …
Call 1-800-823-9633 today!
TDD: 711
8 a.m. to 8 p.m., (7 days a week, Oct . 1 - Feb. 14)
8 a.m. to 8 p.m., (Mon. - Fri., Feb. 15 - Sept. 30)
GeisingerGold.com

      100 N. Academy Avenue • Danville, PA 17822-3240

                                                                    APB_PA_Core_2015
                                                                        APB-335-0814
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