2019 Golden State (HMO) Benefits for Contra Costa County

The following benefit highlight information is for enrollment effective January 1, 2019. You’ll find many $0 benefits, as well as prescription gap coverage, health and wellness programs – and much more.

2019 Benefits Golden State Medicare Gold (HMO)
Monthly Plan Premium* $63
PCP / Specialist Copay $10 / $15
Preventive Services $0
Diagnostic Tests $0
Complex Radiology
(MRI, CT/PET Scan, Therapeutic)
Lab Work $0
Diabetic Supplies
(Lancets, test strips, monitors)
Durable Medical Equipment (DME)
(DME $0 copay for covered items up to $500 & 20% coinsurance of the Medicare Allowable Cost for items over $500)
0-20% copay
Skilled Nursing Facility
(No prior hospital stay required)
$0 (Days 1-20) / $50 (Days 21-100)
Home Health $0
Physical Therapy $0
Hospitalizations $300
Ambulance $200
Emergency Care
(Emergency copay is waived if admitted within 24 hours for the same condition)
Urgent Care
(Urgent Care provided by your PCP is $0 copay)
Outpatient Surgery $100
Outpatient Mental Health $15
Transportation Scheduling
(48 one way trips per year for medical appointments with 24 hours advanced notice)
Vision Services
(Annual eye exam + $150 limit for eyewear every 2 years)
Hearing Test
($400 for 2 hearing aids every 2 years)
Acupuncture (12 office visits) $10
World Wide Coverage
(Emergency Care up to $25,000)
Preventive Dental Care
(Plan offers additional comprehensive benefits.)
Fitness Benefit $0
Tier 1 Preferred Generic Drugs / Mail Order $5 / $10
Tier 2 Generic Drugs / Mail Order $10 / $20
Tier 3 Preferred Brand Drugs / Mail Order $45 / $90
Tier 4 Non-preferred Brand Drugs / Mail Order $95 / $190
Tier 5 Specialty Drugs / Mail Order 33% coinsurance / 33% coinsurance
Gap Coverage - Tier 1 Preferred Generic Drugs $5
Gap Coverage - Tier 2 Generic Drugs $10

*You must continue to pay your Medicare Part B premium

*People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
For more information about Low Income Subsidy with Golden State Medicare Health Plan, click here

Individuals must have both Part A and Part B to enroll in the plan.

You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Golden State Medicare Health Plan will be responsible for the costs.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quanitity limitations and restriction may apply.

Members must receive all routine care from plan providers.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums, co-payments and co-insurance may change on January 1 of each year.