1
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Geisinger Gold Preferred Enhanced Rx (PPO) offered by
Geisinger Indemnity Insurance Company
Annual Notice of Changes for 2024
You are currently enrolled as a member of Geisinger Gold Preferred Enhanced Rx (PPO). Next year,
there will be changes to the plan’s costs and benefits. Please see page 4 for a Summary of Important
Costs, including Premium.
This document tells about the changes to your plan. To get more information about costs, benefits, or
rules please review the Evidence of Coverage, which is located on our website at www.geisingergold.
com. You may also call Member Services to ask us to mail you an Evidence of Coverage.
• You have from October 15 until December 7 to make changes to your Medicare coverage
for next year.
What to do now
1. ASK: Which changes apply to you
Check the changes to our benefits and costs to see if they affect you.
• Review the changes to Medical care costs (doctor, hospital).
• Review the changes to our drug coverage, including authorization requirements and costs.
• Think about how much you will spend on premiums, deductibles, and cost sharing.
Check the changes in the 2024 "Drug List" to make sure the drugs you currently take are still
covered.
Check to see if your primary care doctors, specialists, hospitals, and other providers, including
pharmacies will be in our network next year.
Think about whether you are happy with our plan.
2. COMPARE: Learn about other plan choices
Check coverage and costs of plans in your area. Use the Medicare Plan Finder at www.medicare.
gov/plan-compare website or review the list in the back of your Medicare & You 2024 handbook.
Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s
website.
H3924_23263_4_M Accepted 9/25/23
2
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
3. CHOOSE: Decide whether you want to change your plan
• If you don't join another plan by December 7, 2023, you will stay in Geisinger Gold Preferred
Enhanced Rx (PPO).
• To change to a different plan, you can switch plans between October 15 and December 7. Your
new coverage will start on January 1, 2024. This will end your enrollment with Geisinger Gold
Preferred Enhanced Rx (PPO).
• If you recently moved into, currently live in, or just moved out of an institution (like a skilled
nursing facility or long-term care hospital), you can switch plans or switch to Original Medicare
(either with or without a separate Medicare prescription drug plan) at any time.
Additional Resources
• Please contact our Member Services number at 1-800-498-9731 for additional information. TTY
users should call PA Relay 711 or 1-800-654-5984. (This number requires special telephone
equipment and is only for people who have difficulties with hearing and speaking). Calls to these
numbers are free.
Our business hours:
October 1 - March 31: 8 a.m. - 8 p.m. 7 days a week
April 1 - September 30: 8 a.m. - 8 p.m. Monday - Friday, 8 a.m. - 2 p.m. Saturday
• Member Services has free language interpreter services available for non-English speakers.
Please call the numbers listed in Section 7.1 of this document. We can also give you plan
information in braille, in audio, in large print, or other alternate formats if you need it.
• Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the
Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility
requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/Affordable-
Care-Act/Individuals-and-Families for more information.
About Geisinger Gold Preferred Enhanced Rx (PPO)
• Geisinger Gold Medicare Advantage HMO, PPO, and HMO D-SNP plans are offered by
Geisinger Health Plan/Geisinger Indemnity Insurance Company, health plans with a Medicare
contract. Continued enrollment in Geisinger Gold depends on contract renewal. Geisinger
Health Plan/Geisinger Indemnity Insurance Company are part of Geisinger, an integrated health
care delivery and coverage organization.
• When this document says “we,” “us,” or “our”, it means Geisinger Indemnity Insurance
Company. When it says “plan” or “our plan,” it means Geisinger Gold Preferred Enhanced Rx
(PPO).
3
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Annual Notice of Changes for 2024
Table of Contents
Summary of Important Costs for 2024 .........................................................................................
4
SECTION 1 Changes to Benefits and Costs for Next Year...............................................
8
Section 1.1 – Changes to the Monthly Premium ............................................................................. 8
Section 1.2 – Changes to Your Maximum Out-of-Pocket Amounts ............................................... 9
Section 1.3 – Changes to the Provider and Pharmacy Networks ..................................................... 10
Section 1.4 – Changes to Benefits and Costs for Medical Services ................................................ 10
Section 1.5 – Changes to Part D Prescription Drug Coverage ........................................................ 13
SECTION 2 Administrative Changes .....................................................................................
17
SECTION 3 Deciding Which Plan to Choose ......................................................................
17
Section 3.1 – If you want to stay in Geisinger Gold Preferred Enhanced Rx (PPO) ...................... 17
Section 3.2 – If you want to change plans ...................................................................................... 17
SECTION 4 Deadline for Changing Plans ............................................................................
18
SECTION 5 Programs That Offer Free Counseling about Medicare .............................
19
SECTION 6 Programs That Help Pay for Prescription Drugs .........................................
19
SECTION 7 Questions? ............................................................................................................
20
Section 7.1 – Getting Help from Geisinger Gold Preferred Enhanced Rx (PPO) .......................... 20
Section 7.2 – Getting Help from Medicare ..................................................................................... 20
4
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Summary of Important Costs for 2024
The table below compares the 2023 costs and 2024 costs for Geisinger Gold Preferred Enhanced Rx (PPO)
in several important areas. Please note this is only a summary of costs.
Cost 2023 (this year) 2024 (next year)
Monthly plan premium*
* Your premium may be higher or lower
than this amount. See Section 1.1 for
details.
$0 $0
Maximum out-of-pocket amounts From network providers:
$7,550
From network and
out-of-network providers
combined: $7,550
From network providers:
$7,550
From network and
out-of-network providers
combined: $7,550
This is the most you will pay out-of-pocket
for your covered Part A and Part B
services.
(See Section 1.2 for details.)
Doctor office visits
Primary care visits:
Primary care visits:
In-Network:
$0 copayment per visit
In-Network:
$0 copayment per visit
Out-of-Network:
$0 copayment per visit
Out-of-Network:
$0 copayment per visit
Specialist visits:
Specialist visits:
In-Network:
$35 copayment per visit
In-Network:
$35 copayment per visit
Out-of-Network:
$35 copayment per visit
Out-of-Network:
$35 copayment per visit
5
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Cost 2023 (this year) 2024 (next year)
Inpatient hospital stays In-Network:
$325 copayment for each
Medicare-covered hospital
stay.
Out-of-Network:
$325 copayment for each
Medicare-covered hospital
stay.
For calendar year 2023, the
inpatient hospital stays
benefit will have a service
specific maximum
out-of-pocket of $975. This
means you will not pay any
more than $975 for
inpatient hospital stays.
In-Network:
$325 copayment for each
Medicare-covered hospital
stay.
Out-of-Network:
$325 copayment for each
Medicare-covered hospital
stay.
For calendar year 2024, the
inpatient hospital stays
benefit will have a service
specific maximum
out-of-pocket of $975. This
means you will not pay
more than $975 for
inpatient hospital stays.
Inpatient hospital stays (Psychiatric) In-Network:
$325 copayment for each
Medicare-covered hospital
stay.
Out-of-Network:
$325 copayment for each
Medicare-covered hospital
stay.
For calendar year 2023, the
inpatient hospital stays
(Psychiatric) benefit will
have a service specific
maximum out-of-pocket of
$975. This means you will
not pay any more than $975
for inpatient Psychiatric
care.
In-Network:
$325 copayment for each
Medicare-covered hospital
stay.
Out-of-Network:
$325 copayment for each
Medicare-covered hospital
stay.
For calendar year 2024, the
inpatient hospital stays
(Psychiatric) benefit will
have a service specific
maximum out-of-pocket of
$975. This means you will
not pay more than $975 for
inpatient Psychiatric care.
6
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Cost 2023 (this year) 2024 (next year)
Part D prescription drug coverage
(See Section 1.5 for details.)
In-Network and
Out-of-network
Deductible: $0
In-Network and
Out-of-network
Deductible: $0
Copayment/Coinsurance
during the Initial Coverage
Stage:
Copayment/Coinsurance
during the Initial Coverage
Stage:
• Drug Tier 1: $0
copayment
• Drug Tier 2: $5
copayment
• Drug Tier 3: $47
copayment
You pay no more than $35
per month supply of each
select insulin product.
• Drug Tier 4: $100
copayment
You pay no more than $35
per month supply of each
select insulin product.
• Drug Tier 5: 33%
coinsurance
• Drug Tier 6: $0
copayment
Once your total drug costs
have reached $4,660, you
will move to the next stage
(the Coverage Gap Stage)
• Drug Tier 1: $0
copayment
• Drug Tier 2: $5
copayment
• Drug Tier 3: $47
copayment
You pay no more than
$35 per month supply
of each covered insulin
product.
• Drug Tier 4: $100
copayment
You pay no more than
$35 per month supply
of each covered insulin
product.
• Drug Tier 5: 33%
coinsurance
• Drug Tier 6: $0
copayment
Once your total drug costs
have reached $5,030, you
will move to the next stage
(the Coverage Gap Stage)
Catastrophic Coverage:
• During this payment
stage, the plan pays
most of the cost for
your covered drugs.
Catastrophic Coverage:
• During this payment
stage, the plan pays the
full cost for your
covered Part D drugs.
7
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Cost 2023 (this year) 2024 (next year)
You pay nothing.
• For each prescription,
you pay whichever of
these is larger: a
payment equal to 5% of
the cost of the drug (this
is called coinsurance),
or a copayment ($4.15
for a generic drug or a
drug that is treated like
a generic, and $10.35
for all other drugs).
8
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
SECTION 1 Changes to Benefits and Costs for Next Year
Section 1.1 – Changes to the Monthly Premium
Cost 2023 (this year) 2024 (next year)
Monthly premium
(You must also continue to pay your
Medicare Part B premium.)
$0 $0
Part B Premium Reduction Eligible members may
receive a $25 reduction
on their Part B
Premium. For more
information, see
Chapter 1, Section 4.2
of the Evidence of
Coverage.
Eligible member may
receive a $15 reduction
on their Part B
Premium. For more
information, see
Chapter 1, Section 4.2
of the Evidence of
Coverage.
• Your monthly plan premium will be more if you are required to pay a lifetime Part D late
enrollment penalty for going without other drug coverage that is at least as good as Medicare drug
coverage (also referred to as creditable coverage) for 63 days or more.
• If you have a higher income, you may have to pay an additional amount each month directly to the
government for your Medicare prescription drug coverage.
9
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Section 1.2 – Changes to Your Maximum Out-of-Pocket Amounts
Cost 2023 (this year) 2024 (next year)
In-network maximum
out-of-pocket amount
Your costs for covered medical
services (such as copays) from
network providers count toward your
in-network maximum out-of-pocket
amount. Your plan premium and
your costs for prescription drugs do
not count toward your maximum
out-of-pocket amount.
$7,550
$7,550
Once you have paid $7,550
out-of-pocket for covered
Part A and Part B services you
will pay nothing for your
covered Part A and Part B
services from network
providers for the rest of the
calendar year.
10
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Cost 2023 (this year) 2024 (next year)
Combined maximum out-of-pocket
amount
Your costs for covered medical
services (such as copays) from
in-network and out-of-network
providers count toward your
combined maximum out-of-pocket
amount. Your plan premium and
costs for prescription drugs do not
count toward your maximum
out-of-pocket amount for medical
services.
$7,550 $7,550
Once you have paid $7,550
out-of-pocket for covered
Part A and Part B services, you
will pay nothing for your
covered Part A and Part B
services from network or
out-of-network providers for
the rest of the calendar year.
Medicare requires all health plans to limit how much you pay out-of-pocket for the year. These limits are
called the maximum out-of-pocket amounts. Once you reach this amount, you generally pay nothing for
covered Part A and Part B services for the rest of the year.
Section 1.3 – Changes to the Provider and Pharmacy Networks
Updated directories are located on our website at www.geisingergold.com. You may also call Member
Services for updated provider and/or pharmacy information or to ask us to mail you a directory, which we
will mail within three business days.
There are changes to our network of providers for next year. Please review the 2024 Provider Directory to
see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.
There are changes to our network of pharmacies for next year. Please review the 2024 Provider Directory
to see which pharmacies are in our network.
It is important that you know that we may make changes to the hospitals, doctors and specialists
(providers), and pharmacies that are a part of your plan during the year. If a mid-year change in our
providers affects you, please contact Member Services so we may assist.
Section 1.4 – Changes to Benefits and Costs for Medical Services
We are making changes to costs and benefits for certain medical services next year. The information below
describes these changes.
11
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Cost 2023 (this year) 2024 (next year)
Chiropractic services (in-network)
You pay a $20 copayment for
each Medicare-covered
service.
You pay a $15 copayment for
each Medicare-covered
service.
Chiropractic services (out-of-
network)
You pay a $20 copayment for
each Medicare-covered
service.
You pay a $15 copayment for
each Medicare-covered
service.
Combined Benefit Package
(Flexible Spending Card)
$500 combined in and
out-of-network annual benefit
using a prepaid flexible
spending card to use towards
additional supplemental dental,
supplemental hearing and
supplemental vision covered
services.
$450 combined in and
out-of-network annual benefit
using a prepaid flexible
spending card to use towards
supplemental routine eyewear,
routine hearing exam
copayment, routine eye exam
copayment, additional dental
coverage, hearing aids,
hearing aid fitting and testing.
Emergency Care
You pay a $95 copayment for
each Medicare-covered
service.
Copayment is waived if you
are admitted to a hospital
within 3 days for the same
condition.
You pay a $100 copayment for
each Medicare-covered
service.
Copayment is waived if you
are admitted to a hospital
within 3 days for the same
condition.
Hearing services - Hearing Aids,
Hearing Aid Fitting and Testing
Up to a $100 annual allowance
for both ears combined every
year for hearing aids.
Not covered.
See Combined Benefit Package.
Medicare Part B prescription
drugs (in-network)
You pay a 5% - 20%
coinsurance depending on the
Medicare-covered service.
You pay 5% per month supply
of insulin administered
through an insulin pump.
You pay a 0% - 20%
coinsurance depending on
the Medicare-covered service.
You will pay no more than a
$35 copayment per month
supply for each covered
insulin product.
12
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Cost 2023 (this year) 2024 (next year)
Medicare Part B prescription
drugs (out-of-network)
You pay a 5% - 20%
coinsurance depending on the
Medicare-covered service.
You pay 5% per month supply
of insulin administered
through an insulin pump.
You pay a 0% - 20%
coinsurance depending on the
Medicare-covered service.
You will pay no more than a
$35 copayment per month
supply for each covered
insulin product.
Over the Counter Items (OTC)
You are eligible for $25 every
month to be used toward the
purchase of over-the-counter
(OTC) health and wellness
products.
Unused credits do not roll over
to the next period.
You are eligible for $35 every
month to be used toward the
purchase of over-the-counter
(OTC) health and wellness
products.
Unused credits do not roll over
to the next period.
Pulmonary Rehabilitation Services
(in-network)
You pay a $20 copayment for
each Medicare-covered
service.
You pay a $15 copayment for
each Medicare-covered
service.
Pulmonary Rehabilitation Services
(out-of-network)
You pay a $20 copayment for
each Medicare-covered
service.
You pay a $15 copayment for
each Medicare-covered
service.
Special Supplemental Benefits for
the Chronically Ill (SSBCI)
$1,000 benefit limit per year. Special Supplemental Benefits
for the Chronically Ill (SSBCI)
is not covered.
13
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Cost 2023 (this year) 2024 (next year)
Vision care - Additional routine
eyewear
Up to a $250 combined
benefit every year for all
additional eyewear.
Not covered.
See Combined Benefit
Package.
Worldwide Emergency
Coverage
You pay a $95 copayment per
visit.
$100,000 benefit limit per year
(Combined Worldwide
Emergency/Urgent Coverage)
Waive if admitted.
You pay a $100 copayment per
visit.
$100,000 benefit limit per year
(Combined Worldwide
Emergency/Urgent
Coverage/Ground Ambulance)
Waive if admitted.
Section 1.5 – Changes to Part D Prescription Drug Coverage
Our list of covered drugs is called a Formulary or “Drug List.” A copy of our "Drug List" is provided
electronically.
We made changes to our "Drug List," which could include removing or adding drugs, changing the
restrictions that apply to our coverage for certain drugs or moving them to a different cost-sharing tier.
Review the "Drug List" to make sure your drugs will be covered next year and to see if there will be
any restrictions, or if your drug has been moved to a different cost-sharing tier.
Most of the changes in the "Drug List" are new for the beginning of each year. However, during the year,
we might make other changes that are allowed by Medicare rules. For instance, we can immediately
remove drugs considered unsafe by the FDA or withdrawn from the market by a product manufacturer. We
update our online "Drug List" to provide the most up to date list of drugs.
If you are affected by a change in drug coverage at the beginning of the year or during the year, please
Changes to Our "Drug List"
14
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
review Chapter 5 of your Evidence of Coverage and talk to your doctor to find out your options, such as
asking for a temporary supply, applying for an exception and/or working to find a new drug. You can also
contact Pharmacy Member Services for more information.
Note: If you are in a program that helps pay for your drugs (“Extra Help”), the information about costs
for Part D prescription drugs may not apply to you. We sent you a separate insert, called the “Evidence
of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called the
Low-Income Subsidy Rider or the LIS Rider), which tells you about your drug costs. If you receive “Extra
Help” and you haven’t received this insert by September 30, 2023, please call Member Services and ask for
the LIS Rider.
There are four drug payment stages. The information below shows the changes to the first two stages –
the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two
stages – the Coverage Gap Stage or the Catastrophic Coverage Stage.)
Changes to the Deductible Stage
Stage 2023 (this year) 2024 (next year)
Stage 1: Yearly Deductible Stage
Because we have no
deductible, this payment stage
does not apply to you.
Because we have no
deductible, this payment stage
does not apply to you.
Changes to Prescription Drug Costs
15
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Changes to Your Cost Sharing in the Initial Coverage Stage
Stage 2023 (this year) 2024 (next year)
Stage 2: Initial Coverage Stage
The costs in this row are for a
one-month (30-day) supply when you
fill your prescription at a retail
network pharmacy. For information
about the costs for a
long-term supply or for mail-order
prescriptions, look in Chapter 6,
Section 5 of your Evidence of
Coverage.
We changed the tier for some of the
drugs on our "Drug List." To see if
your drugs will be in a different tier,
look them up on the "Drug List."
Most adult Part D vaccines are
covered at no cost to you.
Your cost for a one-month
supply filled at a retail
network pharmacy:
Your cost for a one-month
supply filled at a retail network
pharmacy:
Tier 1: Preferred Generic:
You pay $0 per prescription.
Tier 1: Preferred Generic:
You pay $0 per prescription.
Tier 2: Generic:
You pay $5 per prescription.
Tier 2: Generic:
You pay $5 per prescription.
Tier 3: Preferred Brand:
You pay $47 per prescription.
You pay no more than $35 per
month supply of each select
insulin product.
Tier 3: Preferred Brand:
You pay $47 per prescription.
You pay no more than $35 per
month supply of each covered
insulin product.
16
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Stage 2023 (this year) 2024 (next year)
Stage 2: Initial Coverage Stage
(continued)
Tier 4: Non-Preferred
Brand:
You pay $100 per prescription.
You pay no more than $35 per
month supply of each select
insulin product.
Tier 4: Non-Preferred Drug:
You pay $100 per prescription.
You pay no more than $35 per
month supply of each covered
insulin product.
Tier 5: Specialty Tier:
You pay 33% of the total cost.
Tier 5: Specialty Tier:
You pay 33% of the total cost.
Tier 6: Vaccines ($0 cost
sharing):
You pay $0 per prescription.
Tier 6: Vaccines ($0 cost
sharing):
You pay $0 per prescription.
Once your total drug costs
have reached $4,660, you will
move to the next stage (the
Coverage Gap Stage).
Once your total drug costs
have reached $5,030, you will
move to the next stage (the
Coverage Gap Stage).
Changes to the Coverage Gap and Catastrophic Coverage Stages
The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage Stage – are
for people with high drug costs. Most members do not reach the Coverage Gap Stage or the
Catastrophic Coverage Stage.
Beginning in 2024, if you reach the Catastrophic Coverage Stage, you pay nothing for covered Part D
drugs.
For specific information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence
of Coverage.
17
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Description 2023 (this year) 2024 (next year)
Over-the-Counter (OTC) InComm Healthcare & Affinity NationsBenefits
Pharmacy Benefit Manager (PBM)
– change in vendor
(Geisinger Health Plan uses a vendor
to process payments for all
prescriptions filled at an outpatient
pharmacy)
PBM Vendor is PerformRx PBM Vendor is Navitus
For additional information
visit GeisingerHealthPlan.
com/find or call Member
Services at 1-800-498-9731.
TTY users should call PA
Relay 711 or 1-800-654-5984
(This number requires special
telephone equipment and is
only for people who have
difficulties with hearing and
speaking).
New ID cards should be
presented at your pharmacy for
prescriptions filled on or after
Jan. 1, 2024.
Section 3.1 – If you want to stay in Geisinger Gold Preferred Enhanced Rx (PPO)
To stay in our plan, you don’t need to do anything. If you do not sign up for a different plan or change to
Original Medicare by December 7, you will automatically be enrolled in our Geisinger Gold Preferred
Enhanced Rx (PPO).
Section 3.2 – If you want to change plans
We hope to keep you as a member next year but if you want to change plans for 2024 follow these steps:
Step 1: Learn about and compare your choices
• You can join a different Medicare health plan,
• – OR– You can change to Original Medicare. If you change to Original Medicare, you will need to
Administrative Changes
SECTION 2
Deciding Which Plan to Choose
SECTION 3
18
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
decide whether to join a Medicare drug plan. If you do not enroll in a Medicare drug plan, please
see Section 1.1 regarding a potential Part D late enrollment penalty.
To learn more about Original Medicare and the different types of Medicare plans, use the Medicare Plan
Finder (www.medicare.gov/plan-compare), read the Medicare & You 2024 handbook, call your State
Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 7.2).
As a reminder, Geisinger Indemnity Insurance Company offers other Medicare health plans. These other
plans may differ in coverage, monthly premiums, and cost-sharing amounts.
Step 2: Change your coverage
• To change to a different Medicare health plan, enroll in the new plan. You will automatically be
disenrolled from Geisinger Gold Preferred Enhanced Rx (PPO).
• To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You
will automatically be disenrolled from Geisinger Gold Preferred Enhanced Rx (PPO).
• To change to Original Medicare without a prescription drug plan, you must either:
○ Send us a written request to disenroll. Contact Member Services if you need more information
on how to do so.
○ -- OR -- Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week, and ask to be disenrolled. TTY users should call 1-877-486-2048.
SECTION 4 Deadline for Changing Plans
If you want to change to a different plan or to Original Medicare for next year, you can do it from October
15 until December 7. The change will take effect on January 1, 2024.
Are there other times of the year to make a change?
In certain situations, changes are also allowed at other times of the year. Examples include people with
Medicaid, those who get “Extra Help” paying for their drugs, those who have or are leaving employer
coverage, and those who move out of the service area.
If you enrolled in a Medicare Advantage Plan for January 1, 2024, and don’t like your plan choice, you can
switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or
switch to Original Medicare (either with or without Medicare prescription drug coverage) between January
1 and March 31, 2024.
If you recently moved into, currently live in, or just moved out of an institution (like a skilled nursing
facility or long-term care hospital), you can change your Medicare coverage at any time. You can change
to any other Medicare health plan (either with or without Medicare prescription drug coverage) or switch to
Original Medicare (either with or without a separate Medicare prescription drug plan) at any time.
19
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
SECTION 5 Programs That Offer Free Counseling about Medicare
The State Health Insurance Assistance Program (SHIP) is an independent government program with trained
counselors in every state. In Pennsylvania, the SHIP is called Pennsylvania Medicare Education and
Decision Insight (PA MEDI).
It is a state program that gets money from the Federal government to give free local health insurance
counseling to people with Medicare. Pennsylvania Medicare Education and Decision Insight (PA MEDI)
counselors can help you with your Medicare questions or problems. They can help you understand your
Medicare plan choices and answer questions about switching plans. You can call Pennsylvania Medicare
Education and Decision Insight (PA MEDI) at 1-800-783-7067. You can learn more about Pennsylvania
Medicare Education and Decision Insight (PA MEDI) by visiting their website (https://www.aging.pa.gov/
aging-services/medicare-counseling/Pages/default.aspx).
SECTION 6 Programs That Help Pay for Prescription Drugs
You may qualify for help paying for prescription drugs. Below we list different kinds of help:
• “Extra Help” from Medicare. People with limited incomes may qualify for “Extra Help” to pay
for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug
costs including monthly prescription drug premiums, annual deductibles, and coinsurance.
Additionally, those who qualify will not have a coverage gap or late enrollment penalty. To see if
you qualify, call:
○ 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7
days a week;
○ The Social Security Office at 1-800-772-1213 between 8 am and 7 pm, Monday through Friday
for a representative. Automated messages are available 24 hours a day. TTY users should call
1-800-325-0778; or
○ Your State Medicaid Office (applications).
• Help from your state’s pharmaceutical assistance program. Pennsylvania has a program called
PACE Program - Prescription Assistance that helps people pay for prescription drugs based on their
financial need, age, or medical condition. To learn more about the program, check with your State
Health Insurance Assistance Program.
• Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance
Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access
to life-saving HIV medications. Individuals must meet certain criteria, including proof of State
residence and HIV status, low income as defined by the State, and uninsured/under-insured status.
Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription
cost-sharing assistance through The Special Pharmaceutical Benefits Program (SPBP). For
information on eligibility criteria, covered drugs, or how to enroll in the program, please call
1-800-922-9384. If you are currently enrolled in an ADAP, it can continue to provide you with
20
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to
be sure you continue receiving this assistance, please notify your local ADAP enrollment worker of
any changes in your Medicare Part D plan name or policy number. For information please call The
State Pharmaceutical Benefit Program (SPBP) customer service at 1-800-922-9384. For information
on eligibility criteria, covered drugs, or how to enroll in the program, please call The State
Pharmaceutical Benefits Program (SPBP) Customer Service number at 1-800-922-9384 or send
questions to https://www.health.pa.gov/topics/programs/HIV/Pages/Special-Pharmaceutical-
Benefits.aspx
SECTION 7 Questions?
Section 7.1 – Getting Help from Geisinger Gold Preferred Enhanced Rx (PPO)
Questions? We’re here to help. Please call Member Services at 1-800-498-9731 or Pharmacy Member
Services at 1-800-988-4861 for additional information. TTY users should call PA Relay at 711 or
1-800-654-5984 (This number requires special telephone equipment and is only for people who have
difficulties with hearing and speaking). Calls to these numbers are free.
Our business hours:
October 1 - March 31: 8 a.m. - 8 p.m. 7 days a week
April 1 - September 30: 8 a.m. - 8 p.m. Monday - Friday, 8 a.m. - 2 p.m. Saturday
Read your 2024 Evidence of Coverage (it has details about next year’s benefits and
costs)
This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2024. For
details, look in the 2024 Evidence of Coverage for Geisinger Gold Preferred Enhanced Rx (PPO). The
Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the
rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of
Coverage is located on our website at www.geisingergold.com. You may also call Member Services to ask
us to mail you an Evidence of Coverage.
Visit our Website
You can also visit our website at www.geisingergold.com. As a reminder, our website has the most
up-to-date information about our provider network (Provider Directory) and our List of Covered Drugs
(Formulary/"Drug List").
Section 7.2 – Getting Help from Medicare
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-633-4227)
You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call
21
Geisinger Gold Preferred Enhanced Rx (PPO)
Annual Notice of Changes for 2024
OMB Approval 0938-1051 (Expires: February 29, 2024)
1-877-486-2048.
Visit the Medicare Website
Visit the Medicare website (www.medicare.gov). It has information about cost, coverage, and quality Star
Ratings to help you compare Medicare health plans in your area. To view the information about plans, go
to www.medicare.gov/plan-compare.
Read Medicare & You 2024
Read the Medicare & You 2024 handbook. Every fall, this document is mailed to people with Medicare. It
has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked
questions about Medicare. If you don’t have a copy of this document, you can get it at the Medicare
website (https://www.medicare.gov/Pubs/pdf/10050-medicare-and-you.pdf) or by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.
