Network Health Anywhere PPO

Southeast Medicare Advantage PPO Plan Benefits

Network Health Anywhere (PPO)

Monthly Premium

Monthly Part B Premium Giveback²

Must be enrolled in Medicare Parts A and B, pay own premiums and live in a service area that offers this benefit.

$26 per month

Annual Medical Deductible

Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

$3,800 combined in- and out-of-network

Primary Care Provider Visit

Specialist Visit

$35

Preventive Care*

Annual Medicare Wellness Visit

Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

Part B Vaccines

Hepatitis B, all other Part B vaccines

Inpatient Hospital Services¹

Per admission

$275 per day, days 1-6
$0 days 7 and beyond

Outpatient Hospital Services¹

$0-$260
$0-$185 at an ambulatory surgical center

Labs

$0-$40

Diagnostic Tests¹

Such as ultrasound, EKG, stress test

$90

X-rays

$90

Diagnostic Radiology Services– Advanced Imaging¹

$310

Urgent Care Visit
Free-standing facility

$35

Emergency Room Visit

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

$125

Air and Ground Ambulance Services

$250

Durable Medical Equipment

Such as insulin pumps¹, CPAP machines¹, prosthetic devices¹

20% of the cost

Home Infusion Therapy

Medical supplies

0% coinsurance

Physician Telehealth Services

Virtual primary care and urgent care services cost the same as an in-person visit

Virtual Visit with MDLIVE^®²

For medical services

Medicare Part B Drugs¹

Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.

20% of the cost

Travel within the United States

Receive in-network coverage when you venture outside Wisconsin and within the United States territories. You can see any provider who accepts Medicare beneficiaries.

International Emergency Coverage

View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details

$125 per incident
$100,000
Maximum benefit

Pick Your Perks²

Not available

Dental Services²

100% coverage for in-network preventive
50% coverage for in-network comprehensive
$2,000 combined annual maximum
Out-of-network: Member pays 80% of allowed amount

Out-of-network dentists do not have a contract with Say Cheese Dental Network, so they have not agreed to a contracted price or payment amount for dental services. Additionally, out-of-network dentists can balance bill you the difference between the charges they bill for their services and Say Cheese Dental Network’s allowed payment amount.

Medicare-Covered Dental Services

Does not include services in connection with care, treatment, filling, removal or replacement of teeth

$35

Optional Comprehensive Dental Coverage²

Not available

Annual Routine Vision Exam²

$0
$40 reimbursement out-of-network

Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

$35

Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

Additional Eyewear²

$350 allowance at EyeMed providers

Over-the-Counter Catalog²

Not available

Fitness with One Pass^™²

Included

Routine Hearing Exam²

$0
$40 out-of-network

Diagnostic Hearing Exam

$35

Hearing Aids²
Maximum of two hearing aids per year
Hearing aid evaluation with TruHearing and fitting included

$495-$1,695 per device
Hearing aids must be purchased through TruHearing
No coverage out-of-network

Outpatient Mental Health

Individual or group therapy

$35

Inpatient Mental Health¹

Per admission

$295 per day, days 1-4
$0 days 5 and beyond

Opioid Treatment Services

$35

Substance Abuse Services

Outpatient individual or group therapy

$35

Skilled Nursing Facility¹

Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day

$0 per day, days 1-20
$214 per day, days 21-45
$0 days 46-100

Outpatient Physical¹, Occupational¹, Speech Therapy

$35

Chiropractic Services

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

$20

Medicare-Covered Acupuncture

For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year

$35

Medicare-Covered Home Health Care Visits¹

Chemotherapy¹

20% of the cost

Radiation Therapy¹
Per service

20% of the cost

Acupuncture³

Up to 12 visits per year are covered for members who are undergoing chemotherapy and have severe nausea and/or vomiting

Diabetes Monitoring Supplies and Test Strips

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.

$0 for up to a 90-day supply

Part B Insulin
One month supply

20% of the cost, up to $35

Diabetic Shoe Inserts

Copayment per pair

$10

Non-Emergency Transportation³

24 one-way trips with Aryv to get to and from dialysis for members with end-stage renal disease (ESRD)

Covered

Dialysis

Per treatment

20% of the cost

*Includes abdominal aortic aneurysm screening, alcohol misuse screening and counseling, annual wellness visit, bone mass measurement, breast cancer screening, cardiovascular disease screening, cardiovascular disease risk reduction visit, cervical and vaginal cancer screening, colorectal cancer screening (screening colonoscopy, fecal occult blood test, flexible sigmoidoscopy), depression screening, diabetes screening, glaucoma screening, HIV screening, lung cancer screening, medical nutrition therapy services, Medicare Diabetes Prevention Program, obesity screening and therapy, prostate cancer screening, screening for sexually transmitted infections and counseling, smoking and tobacco use cessation counseling, one time Welcome to Medicare preventive visit

¹Service may require prior authorization.

²Visit networkhealth.com/medicare/extra-benefits for more information.

³This is a Special Supplemental Benefit for the Chronically Ill (SSBCI) benefit. In addition to an eligible chronic condition, members must also meet additional eligibility requirements to receive the SSBCI benefit.

Network Health Anywhere (PPO) Drug Plan Costs

Annual Drug Deductible

$300 Applies to Tiers 2-5

INITIAL COVERAGE Amount shown is the maximum you will pay, you may pay less.

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

Catastrophic Coverage

You enter catastrophic coverage when your total out-of-pocket costs reach $2,000. You pay $0.

Part D Insulin
One-month supply

$35

Part D Vaccines
Shingrix, Tdap, all other adult ACIP recommended vaccines

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.

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