Medicare Plan Lookup Official CMS data · Contract Year 2027
CMS 2027 data

2027 Medicare plan code

H3924-059

Medicare Plan

Geisinger Gold Preferred Advantage Rx (PPO) · Geisinger Gold · Local PPO · Northeast, Central, & Midwest PA

Full CMS plan ID: H3924-059-021

H3924-059-021 is the full CMS identifier for the H3924-059 Medicare plan. Common searches include H3924 059 and H3924059.

2027

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2027 plan record

Geisinger Gold Preferred Advantage Rx (PPO)

H3924-059-021 Northeast, Central, & Midwest PA Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–6 $200 / day
Days 7–90 $0 / day
Total of listed copays · 6 charged days $1,200
Out-of-network

Tier 1: $200 / day for days 1–6; $0 / day for days 7–90; $0 per stay

Point of service

Not separately reported

02

Emergency transport

Ambulance

Ground · in-network$200 copay
Air · in-network$200 copay
03

Emergency services

Emergency room

$150 copay

Waived if admitted within 3 days

04

Medical maximum

Maximum out-of-pocket

In-network$4,450
Combined in + out$4,450
05

Skilled care at home

Home health

In-network$0 cost share
Out-of-network$0 cost share
06

Monthly cost

Premium & giveback

Part C premium$9 / month
Consolidated C + D$123 / month

CMS reports no Part B premium reduction for this plan.

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkPrimary Care Physician Services: $10 copay
Out-of-network7a: $10 copay

Specialist

In-networkPhysician Specialist Services: $25 copay
Out-of-network7d: $25 copay

Preventive care

In-networkAnnual Physical Exam: $10 copay; Kidney Disease Education Services: $0 cost share; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share
Out-of-network14b: $10 copay; 14d: $0 cost share; 14e1: $0 cost share; 14e2: $0 cost share; 14e4: $0 cost share; 14e5: $0 cost share; 14a: $0 cost share
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-networkDiagnostic Procedures/Tests: $0–$15 copay
Out-of-network8a1: $0–$15 copay

Laboratory services

In-networkLab Services: $15 copay
Out-of-network8a2: $15 copay

X-rays & standard imaging

In-networkOutpatient X-Ray Services: $30 copay
Out-of-network8b3: $30 copay

MRI, CT & PET imaging

In-networkDiagnostic Radiological Services: $0–$275 copay
Out-of-network8b1: $0–$275 copay
Urgent & hospital care6 benefits

Urgent care

In-networkUrgently Needed Services: $25 copay
Out-of-networkNot separately reported

Emergency room

In-network$150 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$200 copay
Out-of-network$200 copay

Air ambulance

In-network$200 copay
Out-of-network$200 copay

Outpatient hospital

In-networkOutpatient Hospital Services: $0–$275 copay; Observation Services: $0–$275 copay
Out-of-network9a1: $0–$275 copay; 9a2: $0–$275 copay

Outpatient surgery / ASC

In-networkAmbulatory Surgical Center (ASC) Services: $0–$275 copay
Out-of-network9b: $0–$275 copay
Recovery & therapy5 benefits

Home health

In-network$0 cost share
Out-of-network$0 cost share

Skilled nursing facility

In-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $160 / day for days 21–100
Out-of-networkSkilled nursing facility: Tier 1: $0 / day for days 1–20; $160 / day for days 21–100; $0 per stay

Cardiac & pulmonary rehabilitation

In-networkCardiac Rehabilitation Services: $20 copay; Intensive Cardiac Rehabilitation Services: $20 copay; Pulmonary Rehabilitation Services: $15 copay; SET for PAD Services: $20 copay; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-network3-1: $20 copay; 3-2: $20 copay; 3-3: $15 copay; 3-4: $20 copay

Occupational therapy

In-networkOccupational Therapy Services: $25 copay
Out-of-network7c: $25 copay

Physical & speech therapy

In-networkPhysical Therapy and Speech-Language Pathology Services: $25 copay
Out-of-network7i: $25 copay
Behavioral health2 benefits

Mental health services

In-networkPartial Hospitalization Program: $55 copay; Individual Sessions for Mental Health Specialty Services: $10 copay; Group Sessions for Mental Health Specialty Services: $5 copay; Individual Sessions for Psychiatric Services: $10 copay; Group Sessions for Psychiatric Services: $5 copay; Inpatient psychiatric hospital: Tier 1: $200 / day for days 1–6; $0 / day for days 7–90
Out-of-network5a: $55 copay; 7e1: $10 copay; 7e2: $5 copay; 7h1: $10 copay; 7h2: $5 copay; Inpatient psychiatric hospital: Tier 1: $200 / day for days 1–6; $0 / day for days 7–90; $0 per stay

Substance use treatment

In-networkIntensive Outpatient Program Services: $55 copay; Individual Sessions for Outpatient Substance Abuse: $10 copay; Group Sessions for Outpatient Substance Abuse: $5 copay
Out-of-network5b: $55 copay; 9c1: $10 copay; 9c2: $5 copay
Specialty care2 benefits

Podiatry

In-networkPodiatry Services: $25 copay
Out-of-network7f: $25 copay; 7f_2: $0 cost share

Chiropractic

In-networkChiropractic Services: $20 copay
Out-of-network7b: $20 copay
Supplemental benefits7 benefits

Dental

In-networkMedicare Dental Services: $25 copay
Out-of-network16a: $25 copay

Vision

In-networkEye Exams: $0–$25 copay; Routine Eye Exams: Not applicable; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: Not applicable; Eyeglasses (lenses and frames): Not applicable; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
Out-of-network17a: $0–$25 copay; 17b: $0 cost share

Hearing

In-networkHearing Exams: $25 copay; Routine Hearing Exams: Not applicable; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): Not applicable; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-network18a: $25 copay

Transportation

Not applicable
In-network10b(NMC): Not applicable
Out-of-networkNot separately reported

Fitness & wellness

Not applicable
In-networkFitness Benefit: Not applicable
Out-of-networkNot separately reported

Over-the-counter allowance

Not applicable
In-networkOver-the-Counter (OTC) Items: Not applicable
Out-of-networkNot separately reported

Meals

Not applicable
In-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$9 Part C premium / month · CMS reports no Part B premium reduction for this plan.

Maximum out-of-pocket (MOOP)

In-network$4,450
Combined in + out$4,450

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Annual health deductible

$0

Combined network deductible

Not separately reported

Part D premium

$114 / month

Network & referrals

Local PPO · Referrals: Not required · Out-of-network coverage: Yes

Prescription drugs6 tiers

Part D deductible

$0 / year

Drug tier 1

Standard retail: $1 copay · Preferred retail: $1 copay · 30-day supply

Drug tier 2

Standard retail: $2 copay · Preferred retail: $2 copay · 30-day supply

Drug tier 3

Standard retail: 25% coinsurance · Preferred retail: 25% coinsurance · 30-day supply

Drug tier 4

Standard retail: 49% coinsurance · Preferred retail: 49% coinsurance · 30-day supply

Drug tier 5

Standard retail: 33% coinsurance · Preferred retail: 33% coinsurance · 30-day supply

Drug tier 6

Standard retail: $0 copay · Preferred retail: $0 copay · 30-day supply

Using this plan

Understand H3924-059-021

Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

Geisinger Gold Preferred Advantage Rx (PPO) is a 2027 Local PPO offered by Geisinger Gold in Northeast, Central, & Midwest PA. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $1,200 across 6 charged days.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
Primary Care Physician Services: $10 copay
Specialist
Physician Specialist Services: $25 copay
Laboratory services
Lab Services: $15 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
Diagnostic Procedures/Tests: $0–$15 copay
MRI, CT & PET imaging
Diagnostic Radiological Services: $0–$275 copay
Outpatient hospital
Outpatient Hospital Services: $0–$275 copay; Observation Services: $0–$275 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$150 copay
Listed inpatient stages
$1,200 total

6 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Part B premium reduction (“giveback”)

A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports no Part B premium reduction for this plan.

Availability

Who can enroll

Service area
Northeast, Central, & Midwest PA (PA)
Plan type
Local PPO
Contract / plan
H3924-059
Coverage year
2027

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

DentalMedicare Dental Services: $25 copay
VisionEye Exams: $0–$25 copay; Routine Eye Exams: Not applicable; Other Eye Exam Services: Not applicable; Eyewear: $0 cost share; Contact Lenses: Not applicable; Eyeglasses (lenses and frames): Not applicable; Eyeglass lenses: Not applicable; Eyeglass frames: Not applicable; Upgrades: Not applicable
HearingHearing Exams: $25 copay; Routine Hearing Exams: Not applicable; Fitting/Evaluation for Hearing Aid: Not applicable; Prescription Hearing Aids (all types): Not applicable; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable

Plan-specific answers

Frequently asked questions

Where is H3924-059-021 available?

Geisinger Gold Preferred Advantage Rx (PPO) is listed for Northeast, Central, & Midwest PA (PA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H3924-059-021?

The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $4,450. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H3924-059-021?

The listed consolidated Part C and Part D premium is $123 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H3924-059-021?

The plan record lists $150 copay, waived when an admission meets the plan's stated timing rule.

Does H3924-059-021 report extra benefits?

Yes. CMS reports dental, vision, hearing. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2027

Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H3924-059-021 fits

Full CMS plan ID
H3924-059-021
Contract
H3924
Base plan code
H3924-059
Segment
021
Carrier
Geisinger Gold
Plan type
Local PPO
Service area
Northeast, Central, & Midwest PA (PA)

County/service-area foundation

CMS service-area entries

Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.

  • Blair, PA
  • Bradford, PA
  • Cambria, PA
  • Cameron, PA
  • Centre, PA
  • Clearfield, PA
  • Clinton, PA
  • Columbia, PA
  • Fulton, PA
  • Huntingdon, PA
  • Jefferson, PA
  • Juniata, PA

17 additional service-area entries are retained in the data record.

Exact county navigation

These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.

Show 29 county links
Pennsylvania

Same CMS contract

H3924-059-022 Geisinger Gold Preferred Advantage Rx (PPO) South & East Pennsylvania · Local PPO H3924-065-000 Geisinger Gold Preferred Complete Rx (PPO) Pennsylvania · Local PPO H3924-067-000 Geisinger Gold Preferred Balance Rx (PPO) Pennsylvania · Local PPO H3924-804-000 Geisinger Gold Preferred Basic/Deluxe Rx (+) EGWP (PPO) Pennsylvania · Local PPO H3924-805-000 Geisinger Gold Preferred Basic/Deluxe (+) EGWP (PPO) Pennsylvania · Local PPO

About this code

What H3924-059-021 identifies

H3924-059-021 is a Contract Year 2027 Medicare plan segment code. Searches written as H3924-059, H3924 059, or the compact full CMS ID H3924059021 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.