Northeast Medicare Advantage PPO Plan Benefits
Network Health Armor (PPO)
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.
$55 per month
Annual Medical Deductible
$0
Annual Maximum Out-of-Pocket
$4,900 combined in- and out-of-network
Primary Care Provider Visit
$0
Annual Medicare Wellness Visit
$0
Medicare-Covered Vaccines
Flu, pneumonia, COVID-19
$0
Part B Vaccines
Hepatitis B1, all other Part B vaccines
$0
Inpatient Hospital Services 1
Per admission
$295 per day, days 1 - 6
$0 days 7 and beyond
Outpatient Hospital Services 1
$275
Ambulatory Surgical Center 1
$225
Diagnostic Tests 1
Such as ultrasound, EKG, stress test
$40
Diagnostic Radiology Services– Advanced Imaging 1
$125
Urgent Care Visit
Free-standing facility
$40
Emergency Room Visit
Copayment is waived if admitted to a U.S. hospital within 24 hours
$130
Air and Ground Ambulance Services
$300
Durable Medical Equipment
Such as insulin pumps1, CPAP machines, prosthetic devices1
20% of the allowed amount
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
$0
Medicare Part B Drugs 1
20% of the cost
Medicare Part D Drugs
Not covered
Travel within the United States
Receive in-network coverage when you venture outside Wisconsin and within the United States and its territories. You can see any provider who accepts Medicare beneficiaries.
$130 per incident
$100,000
Maximum benefit
Pick Your Perks 2
Not available
Dental Services 2
100% coverage for in-network dental
$3,500 combined annual maximum
Out-of-network: Member pays 50% of the 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
$40
Optional Comprehensive Dental Coverage 2
Not available
Annual Routine Vision Exam 2
$0
$40 reimbursement out-of-network
Diagnostic Eye Exam
To diagnose and treat diseases and conditions of the eye
$40
Post-Cataract Eyewear
One pair of eyeglasses or contact lenses after each cataract surgery
$0
Additional Eyewear 2
$400 allowance at EyeMed providers, or
$400 reimbursement out-of-network
Over-the-Counter Catalog 2
Two order per quarter
$100 per quarter
No rollover on quarterly allowance.
Fitness with One Pass ™ 2
In-Network: $0
Routine Hearing Exam 2
In-Network: $0
Diagnostic Hearing Exam
Exam to diagnose and treat hearing issues
$40
Fitting/Evaluation for Hearing Aids
In-Network: $0
Hearing Aids 2
Maximum of two hearing aids per year
Hearing aid evaluation with TruHearing and fitting included
In-Network: $495-$1,695 per device
Hearing aids must be purchased through TruHearing
Outpatient Mental Health
Individual or group therapy
$20
Inpatient Mental Health 1
Per admission
$395 per day, days 1 - 4
$0 days 5 and beyond
Opioid Treatment Services
$20
Substance Abuse Services
Outpatient individual or group therapy
$20
Skilled Nursing Facility 1
Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day
$0 per day, days 1 - 20
$221 per day, days 21 - 45
$0 days 46 - 100
Outpatient Physical 1, Occupational 1, Speech Therapy
$30
Medicare-Covered Chiropractic Services
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
$15
Medicare-Covered Acupuncture
For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year
$40
Medicare-Covered Home Health Care Visits 1
$0
Chemotherapy 1
20% of the allowed amount
Radiation Therapy 1
20% of the allowed amount
Diabetes Monitoring Supplies and Test Strips
Accu-Chek™ and FreeStyle™ test strips
FreeStyle Libre® and Dexcom®continuous glucose monitoring devices and supplies1 obtained through your pharmacy. Must have diabetic diagnosis. All other brands are not covered
$0 for up to a 90-day supply
Diabetic Shoe Inserts
Copayment per pair
$10
Part B Insulin1
One month supply
No more than $35
20% of the allowed amount
*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
1 Service may require prior authorization.