Arizona

Gold Circle Dialysis

(H4869-012)

For those Medicare eligible who are on dialysis and have access to other forms of coverage

Counties: Cochise, Coconino, Gila, Graham, Maricopa, Navajo, Pima, Pinal

$0

Monthly Premium

$590

Rx deductible

25%

Rx copay

4G Smartphone*

This benefit is supplied through Gold Kidney’s mobile phone and services partner and includes unlimited talk, text, and data

$1,200 healthy food allowance* per year

This allowance is distributed monthly, without rollover, for healthy food, produce, and prepared meals

$1,200 fuel and rideshare allowance* per year

This allowance is distributed monthly, without rollover, for fuel and rideshare expenses

$200 alternative therapy allowance per year

This allowance is distributed quarterly, without rollover, for the services of a medicine man (a man or woman) from a Native

$300 in rewards & incentives per year

This program offers rewards for the completion of plan-defined preventive activities

Rx Benefits

Rx deductible

$590

This is what you will pay before Gold Kidney starts paying for covered prescription medications

30-day Rx copay
(Tiers 1-5)

25% / 25% / 25% / 25% / 25%

This is what you will pay for prescription medications

100-day mail order Rx
(Tiers 1–5)

25% / 25% / 25% / 25% / 25%

This is what you will pay for a long-term supply of prescription medications through a convenient mail-order service

Gold Perks

Gold Perks Plus

Utility bills*
Pest control services*
Over-the-counter items (OTC)
Indoor air quality equipment and Services*
Therapeutic massage
Personal care services*
Fitness activity fees
Home and bathroom safety devices
Pet supplies and services*

Additional Benefits**

**Refer to the Summary of Benefits for specific benefits and coverage amounts

4G smartphone with unlimited talk, text, and data*

$1,200 annual allowance for healthy food, and produce*

2 prepared meals per day, for 14 days, up to 4 times per year following surgery or an in-patient hospitalization

$1,200 annual allowance for fuel and rideshare services*

Up to $300 annually in Rewards & Incentives for preventive health activities

Ready to get started?

The process is easy!

Want more plan details?

Ready to enroll?

Have more questions?

¹If you receive Medicaid/AHCCS benefits, your premium and coinsurance will be paid by these programs.

*Requires one of the CMS-listed chronic illnesses, SSBCI program requirements, and participation in the Gold Kidney’s care management program for C-SNP plan members. Learn more about SSBCI here

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Arizona

Gold Circle Dialysis

(H4869-012)

$0

Monthly Premium

$590

Rx deductible

25%

Rx copay

Rx Benefits

Rx deductible

30-day Rx copay (Tiers 1-5)

100-day mail order Rx (Tiers 1–5)

Gold Perks

Gold Perks Plus

Additional Benefits**

4G smartphone with unlimited talk, text, and data*

$1,200 annual allowance for healthy food, and produce*

2 prepared meals per day, for 14 days, up to 4 times per year following surgery or an in-patient hospitalization

$1,200 annual allowance for fuel and rideshare services*

Up to $300 annually in Rewards & Incentives for preventive health activities

Ready to get started?

The process is easy!

Want more plan details?

Ready to enroll?

Have more questions?

For all inquiries, please call Member Services at (844) 294-6535

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30-day Rx copay
(Tiers 1-5)

100-day mail order Rx
(Tiers 1–5)