Geisinger Gold Preferred Basic/Deluxe (+) EGWP (PPO)

GEISINGER INDEMNITY INSURANCE COMPANY · 2026 plan year

Plan ID H3924-805-000

Local PPO★ 4.5 CMS StarsNew for 2026Employer group plan

MOOP (in-network): $8,000
MOOP (combined): $8,000
Monthly premium: Not published; CMS publishes no consumer premium for this plan
Prescription drugs: Included

Offered only through an employer or union retiree plan; premiums are set by the group.

This plan in 2027

Geisinger Gold Preferred Basic/Deluxe (+) EGWP (PPO)Compare 2026 vs 2027

Plan information

Contract / Plan / Segment: H3924-805-000
Medical deductible: $0 — no deductible

More GEISINGER INDEMNITY INSURANCE COMPANY plans in PA

Geisinger Gold Preferred Advantage Rx (PPO)Geisinger Gold Preferred Advantage Rx (PPO)Geisinger Gold Preferred Basic/Deluxe Rx (+) EGWP (PPO)Geisinger Gold Preferred Complete Rx (PPO)

Benefits & cost sharing

Hospital

Benefit	In-network
Inpatient Hospital — Acute	Original Medicare cost sharing
Inpatient Hospital — Psychiatric	Original Medicare cost sharing

Pharmacy

Benefit	In-network
Part B Drugs	See plan details
Chemotherapy & Radiation Drugs (Part B)	0%-20% coinsurance
Other Part B Drugs	0%-20% coinsurance

Mental Health

Benefit	In-network
Mental Health Specialty Services	See plan details
Mental Health — Individual Sessions	20% coinsurance
Mental Health — Group Sessions	20% coinsurance

Other

Benefit	In-network
Outpatient Substance Abuse Services	See plan details
Ambulance Services	See plan details
Dental — Medicare-Covered Services	$35
Vision — Eye Exams	20% coinsurance
Vision — Eyewear	20% coinsurance
Hearing — Exams	20% coinsurance
Radiological Services	See plan details
Skilled Nursing Facility (SNF)	Original Medicare cost sharing
Cardiac & Pulmonary Rehabilitation	See plan details
Cardiac Rehabilitation — Additional Sessions	20% coinsurance
Intensive Cardiac Rehabilitation — Additional Sessions	20% coinsurance
Pulmonary Rehabilitation — Additional Sessions	20% coinsurance
Supervised Exercise Therapy (SET)	20% coinsurance
Emergency Services	20% coinsurance (max $115)
Urgently Needed Services	20% coinsurance (max $40)
Partial Hospitalization Program	20% coinsurance
Intensive Outpatient Program (IOP)	20% coinsurance
Home Health Services	No charge
Primary Care Physician Services	20% coinsurance
Chiropractic Services	20% coinsurance
Occupational Therapy Services	20% coinsurance
Physician Specialist Services	20% coinsurance
Podiatry Services	20% coinsurance
Other Health Care Professional Services	20% coinsurance
Psychiatric Services	See plan details
Welcome to Medicare EKG	No charge
Psychiatric Services — Individual Sessions	$10
Psychiatric Services — Group Sessions	$5
Physical Therapy & Speech-Language Pathology	$35
Additional Telehealth Services (Part B)	$0-$35
Opioid Treatment Program Services	20% coinsurance
Diagnostic Tests & Lab Services	See plan details
Diagnostic Procedures & Tests	$20
Laboratory Services	$20
Diagnostic Radiology	$40-$290
Therapeutic Radiology	$40-$60
X-Ray Services	$40
Outpatient Hospital Services	$0-$350
Hospital Observation Services	$0-$350/day
Ambulatory Surgical Center (ASC)	$0-$350
Substance Abuse — Individual Sessions	$10
Substance Abuse — Group Sessions	$5
Outpatient Blood Services	No charge
Ground Ambulance	$275
Air Ambulance	$275
Durable Medical Equipment (DME)	20% coinsurance
Prosthetics & Orthotics	See plan details
Prosthetic Devices	20% coinsurance
Medical Supplies	20% coinsurance
Diabetic Supplies & Services	See plan details
Diabetic Therapeutic Shoes & Inserts	20% coinsurance
Dialysis Services	10%-20% coinsurance
Medicare-Covered Preventive Services	See plan details
Kidney Disease Education Services	No charge
Glaucoma Screening	No charge
Diabetes Self-Management Training	No charge
Digital Rectal Exams	No charge
Insulin (Part B)	0%-20% coinsurance (max $35)
Diabetic Supplies	0%-20% coinsurance

Service area

PA: 67 counties

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