Northeast Medicare Advantage PPO Plan Benefits
Network Health Armor (PPO)
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 B, 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
$0-$275
Ambulatory Surgical Center 1
$0-$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
$125
Air and Ground Ambulance Services
$300
Durable Medical Equipment
Such as insulin pumps1, CPAP machines1, prosthetic devices1
20% of the cost
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
Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.
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.
$125 per incident
$100,000
Maximum benefit
Pick Your Perks 2
Not available
Dental Services 2
100% coverage for in-network dental
Includes one implant and resin
$5,000 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
Over-the-Counter Coverage 2
Two order per quarter
$100 per quarter
No rollover on quarterly allowance
Fitness with One Pass ™ 2
Included
Routine Hearing Exam 2
$0
$40 out-of-network
Diagnostic Hearing Exam
$40
Hearing Aids 2
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
$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
$214 per day, days 21 - 45
$0 days 46 - 100
Outpatient Physical 1, Occupational 1, Speech Therapy
$30
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
$40
Medicare-Covered Home Health Care Visits 1
$0
Chemotherapy 1
20% of the cost
Radiation Therapy 1
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
$0
Diabetes Monitoring Supplies and Test Strips
One Touch ™ and FreeStyle ™ test strips
Continuous glucose monitoring 1 supplies 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
Diabetic Shoe Inserts
Copayment per pair
$10
Part B Insulin
One month supply
20% of the cost, up to $35
Non-Emergency Transportation3
24 one-way trips to get to and from dialysis for members diagnosed with end-stage renal disease (ESRD)
Covered
*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.
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.