Ideal for those who prefer to pay the same for in- and out-of-network services.
_$0
Enroll NowMust be enrolled in Medicare Parts A and B, pay own premiums and live in a service area that offers this benefit.
(Does not include Part D prescription drugs)
Flu, pneumonia, COVID-19
Hepatitis B, all other Part B vaccines
Per admission
Such as ultrasound, EKG, stress test
Copayment is waived if admitted to a U.S. hospital within 24 hours
Such as insulin pumps1, CPAP machines1, prosthetic devices1
Medical supplies
For medical services
Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.
View the Evidence of Coverage at networkhealth.com/
Does not include services in connection with care, treatment, filling, removal or replacement of teeth
To diagnose and treat diseases and conditions of the eye
One pair of eyeglasses or contact lenses after each cataract surgery
Individual or group therapy
Per admission
Outpatient individual or group therapy
Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year
Up to 12 visits per year are covered for members who are undergoing chemotherapy and have severe nausea and/or vomiting
One Touch™ and FreeStyle™ test strips
Continuous glucose monitoring supplies1 limited to eligible FreeStyle Libre® and Dexcom® obtained through your pharmacy. All other brands are not covered.
Copayment per pair
24 one-way trips with Aryv to get to and from dialysis for members with end-stage renal disease (ESRD)
Per treatment
30-Day Supply
Preferred Pharmacy or Preferred Mail Order Pharmacy
$2 for Tier 1
$8 for Tier 2
23% for Tier 3
37% for Tier 4
29% of the cost for Tier 5
3-Month Supply
Preferred Pharmacy
100-day for Tier 1
90-day for Tier 2-4
$5 for Tier 1
$20 for Tier 2
23% for Tier 3
37% for Tier 4
Tier 5 is not available
31 to 100-Day Supply
Preferred Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2
$0 for Tier 1
$0 for Tier 2 after deductible
3-Month Supply
Preferred Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2-4
$0 for Tier 1
$0 for Tier 2 after deductible
23% for Tier 3
37% for Tier 4
Tier 5 is not available
30-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy
$7 for Tier 1
$15 for Tier 2
24% for Tier 3
37% for Tier 4
29% of the cost for Tier 5
3-Month Supply
Standard Pharmacy or Standard Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2-4
$17 for Tier 1
$37 for Tier 2
24% for Tier 3
37% for Tier 4
Tier 5 is not available
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.