Arizona

Gold Loyalty

(H4869-009)

For those who are Medicare-eligible and do not need prescription drug coverage

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

$0

Monthly Premium

$0

Copay for PCPs

$75

Part B giveback

$2,500 Flex allowance per year

This allowance is distributed quarterly, with rollover, for dental, vision, and hearing expenses

$600 Gold Perks allowance per year

This benefit package is distributed monthly, without rollover, for the purchase of plan-defined product and service categories

Silver&Fit gym membership

This benefit includes a comprehensive fitness and well-being program

$300 in rewards & incentives per year

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

In-home support & companionship

This benefit provides up to 60 hours per year of in-home support for activities such as light household chores

Personal emergency response device

This benefit provides one wearable PERS device per year to connect members to urgent support resources

Rx Benefits

Rx deductible

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

30-day Rx copay
(Tiers 1-6)

$0 / $5 / $47 / $100 / 33%

This is what you will pay for prescription medications

100-day mail order Rx
(Tiers 1–6)

$0 / $5 / $40 / $250

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

Gold Perks

$600 Annual Allowance

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

$2,500 annual Flex allowance for dental, vision, and hearing, with quarterly rollover

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

Silver&Fit gym membership with a comprehensive fitness and well-being program

60 hours of in-home companionship and support annually

Wearable personal emergency response device equipped with GPS and fall-detection

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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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