Arizona

Gold Dialysis & Kidney

(H4869-013)

For those who are Medicare-eligible and have end-stage renal disease (ESRD), generally requiring dialysis

Counties: Cochise, Coconino, Graham, Navajo

$0

Copay for PCPs and most specialists

$0

Copay for Dialysis

$0

Rx deductible and Insulin (Tier 6) copay

$2,000 Flex allowance per year

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

4G Smartphone*

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

$900 healthy food allowance* per year

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

$900 fuel and rideshare allowance* per year

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

$300 Gold Perks Plus allowance per year

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

Pre- and post-kidney transplant assistance

This benefit provides additional dental benefits and caretaker assistance for pre- and post-kidney transplant

Rx Benefits

Rx deductible

$0

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% / $0

This is what you will pay for prescription medications

100-day mail order Rx
(Tiers 1–6)

$0 / $5 / $40 / $250 / NA / $0

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

Gold Perks Plus

$300 Annual Allowance

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

$2,000 annual Flex allowance for dental, vision, and hearing, with quarterly rollover

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

$900 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

$900 annual allowance for fuel and rideshare services*

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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