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Medicare Plans

Plan Details

Network PlatinumPlus Pharmacy (PPO)

Ideal for those who prefer low limit on costs and affordable premiums.



$124 per month

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  • Same costs for in- and out-of-network providers
  • $0 medical deductible
  • $0 copayment for 90-day mail order Tier 1 drugs
  • $10 copayment for an in-network annual eye exam
  • $15 copayment for primary care provider visits
  • $120 emergency room visit
  • $3,400 maximum out-of-pocket (combined in- and out-of-network)
  • 100% coverage for preventive care
  • Prescription drug coverage
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Hearing aid discount benefit
  • Annual dental exam and cleaning

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPlus Pharmacy (PPO)

1Service may require prior authorization. for more information.

Monthly Premium
$124 per month (includes pharmacy)
Annual Medical Deductible
Annual Maximum Out-of-Pocket

Combined in-and out-of-network (Does not include prescription drugs)

Inpatient Hospital1

Per admission

$175 per day, Days 1-5, $0 Days 6 and beyond
Outpatient Surgery Services


Primary Care Provider Visit
Specialist Visit
Preventive Care
Emergency Room Visit

Copayment is waived if admitted to a U.S. hospital within 24 hours.

Urgent Care
Diagnostic Lab Tests
Diagnostic Tests

Such as ultrasound, EKGs, stress test

Radiation Therapy1

Per service

Diagnostic Radiology Services1

Such as MRIs, CT Scans

Outpatient Ambulatory Surgical Center Services

Such as diagnostic colonoscopies

Preventive Dental Exam2

One exam and cleaning per year, X-rays are not included

In-network: $30 
Out-of-network: $100 reimbursement

Medicare-Covered Dental Services
Comprehensive Dental Benefit2
$38 monthly premium Annual Maximum: $1,000
Routine Eye Exam2
$10 in-network, $40 reimbursement out-of-network 
Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

Inpatient Mental Health1

Per admission

$150 per day, Days 1-10, $0 Days 11 and beyond
Outpatient Mental Health

Individual or group therapy


Skilled Nursing Facility1

per admission

$20 per day, Days 1-20, $184 per day, Days 21-54, $0 per day, Days 55-100
Physical, Occupational, Speech Outpatient Therapy

Includes comprehensive outpatient rehabilitation facility.

Ambulance - Air and Ground Services
Transportation - Non-Emergency 

Includes 24 one-way trips for all members diagnosed with end stage renal disease (ESRD), to get to and from dialysis for treatment

Medicare Part B Drugs and Chemotherapy1
20% of the cost
Medicare Part D Drugs

See presciription drug chart for tier information

Chiropractic Services

Manipulation of the spine to correct misalignment of one or more of the bones of your spine.

Diabetes Monitoring Supplies and Test Strips1

One Touch™ and Accu-Chek™ test strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered.

$0 for up to a 90-day supply

Per treatment

20% of the cost
Diabetic Shoe Inserts

Copayment per pair

Durable Medical Equipment

Such as insulin pumps, CPAP machines, prosthetic devices1

20% of the cost
Medicare-Covered Home Health Care Visits1
Virtual Visits2

Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®2

Hearing Aids2

Includes a three-year warranty with loss and damage insurance, up to six hearing aid follow up visits within three years and 16 batteries. Maximum of two hearing aids per year.

Select hearing aids discounted to
$795-$2,370 per device.
A savings of up to $1,050 per hearing aid.
Additional Eyewear2

SilverSneakers® Fitness2
Over-the-Counter Coverage2

No rollover on quarterly allowance

$50 allowance per quarter
Pick Your Perks Reimbursement Program2

Reimbursement for Medicare-approved supplemental benefits including dental, vision, vision hardware, meals, non-emergency transportation, over-the-counter items, acupuncture, massage thereapy expenses and nutritional/dietary benefits

Not included

Network PlatinumPlus Pharmacy (PPO) Drug Plan Costs

Your coverage starts, when you have a $0 deductible for Tiers 1-3
Drug Deductible
$260 for Tiers 4 and 5 only
Initial Coverage

30-Day Supply Preferred
Pharmacy or Mail Order Pharmacy
$2 for Tier 1      $42 for Tier 3
$8 for Tier 2      $90 for Tier 4
28% of the cost for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1     $47 for Tier 3
$14 for Tier 2   $100 for Tier 4
28% of the cost for Tier 5

90-Day Supply Preferred Pharmacy
$5 for Tier 1      $105 for Tier 3
$20 for Tier 2    $225 for Tier 4
Tier 5 is not available

90-Day Supply Standard Pharmacy
$10 for Tier 1     $118 for Tier 3
$35 for Tier 2     $250 for Tier 4
Tier 5 is not available

31 to 90-Day Supply Mail Order Pharmacy
$0 for Tier 1

90-Day Supply Mail Order Pharmacy
$0 for Tier 1       $105 for Tier 3
$20 for Tier 2     $225 for Tier 4
Tier 5 is not available

Coverage Gap
You enter the coverage gap when total drug costs reach $4,130. You pay 25% and Network Health pays 75% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.
Catastrophic Coverage
You enter catastrophic coverage when your true out-of-pocket costs reach $6,550. You pay the greater of $3.70 or 5% of the cost for generic drugs and $9.20 or 5% of the cost for brand name drugs.

This information is not a complete description of benefits. Call 800-378-5234 (TTY 800-947-3529) for more information. Out-of-network/non-contracted providers are under no obligation to treat Network Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Network Health
1570 Midway Place
Menasha, WI 54952
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.