Southeast Medicare Advantage PPO Plan Benefits
Network Health Bravo (PPO)
Annual Medical Deductible
$0
Annual Maximum Out-of-Pocket
(Does not include Part D prescription drugs)
In-network: $4,500
Out-of-network: $8,000 combined in- and out-of-network
Primary Care Provider Visit
In-network: $0
Out-of-network: $30
Specialist Visit
In-network: $40
Out-of-network: $75
Preventive Care*
In-network: $0
Out-of-network: $15
Annual Medicare Wellness Visit
In-network: $0
Out-of-network: $15
Medicare-Covered Vaccines
Flu, pneumonia, COVID-19
In-network: $0
Out-of-network: $0
Part B Vaccines
Hepatitis B, all other Part B vaccines
In-network: $0
Out-of-network: $15
Inpatient Hospital Services1
Per admission
In-network:
$295 per day, days 1-6
$0 days 7 and beyond
Out-of-network:
$550 per day, days 1-6
$0 days 7 and beyond
Outpatient Hospital Services1
In-network: $0-$275
Out-of-network: $0-$450
Ambulatory Surgical Center1
In-network: $0-$225
Out-of-network: $0-$450
Labs
In-network: $0-$20
Out-of-network: $30
Diagnostic Tests1
Such as ultrasound, EKG, stress test
In-network: $20
Out-of-network: $50
X-rays
In-network: $35
Out-of-network: $40
Diagnostic Radiology Services– Advanced Imaging1
In-network: $200
Out-of-network: $250
Urgent Care Visit
Free-standing facility
In-network: $45
Out-of-network: $45
Emergency Room Visit
Copayment is waived if admitted to a U.S. hospital within 24 hours
In-network: $125
Out-of-network: $125
Air and Ground Ambulance Services
In-network: $300
Out-of-network: $300
Durable Medical Equipment1
Such as insulin pumps, CPAP machines, prosthetic devices
In-network: 20% of the cost
Out-of-network: 25% 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
In-network: $0
Medicare Part B Drugs1
Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.
In-Network: 20% of the cost
Out-of-Network: 50% 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 territories. You can see any provider who accepts Medicare beneficiaries.
In-network: $125 per incident | $100,000 Maximum benefit
Out-of-network: $125 per incident | $100,000 Maximum benefit
Pick Your Perks2
In-network: Not available
Out-of-network: Not available
Dental Services2
In-network: 100% coverage, 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
In-network: $40
Out-of-network: $75
Optional Comprehensive Dental Coverage2
In-network: Not available
Out-of-network: Not available
Annual Routine Vision Exam2
In-network: $0
Out-of-network: $40 reimbursement
Diagnostic Eye Exam
To diagnose and treat diseases and conditions of the eye
In-network: $40
Out-of-network: $75
Post-Cataract Eyewear
One pair of eyeglasses or contact lenses after each cataract surgery
In-network: $0
Out-of-network: $75
Additional Eyewear2
In-network: $400 allowance at EyeMed providers
Out-of-network: Not covered
Over-the-Counter Coverage2
Two orders per quarter
In-network: $100 per quarter | No rollover on quarterly allowance
Out-of-network: Not available
Fitness with One Pass™2
In-network: Included
Routine Hearing Exam2
In-network: $0
Out-of-network: $40
Diagnostic Hearing Exam
In-network: $40
Out-of-network: $75
Hearing Aids2
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
Out-of-network: No coverage
Outpatient Mental Health
Individual or group therapy
In-network: $20
Out-of-network: $20
Inpatient Mental Health1
Per admission
In-network:
$395 per day, days 1-4
$0 days 5 and beyond
Out-of-network:
$395 per day, days 1-4
$0 days 5 and beyond
Opioid Treatment Services
In-network: $20
Out-of-network: $20
Substance Abuse Services
Outpatient individual or group therapy
In-network: $20
Out-of-network: $20
Skilled Nursing Facility1
Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day
In-network:
$0 per day, days 1-20
$214 per day, days 21-45
$0 days 46-100
Out-of-network:
$214 per day, days 1-45
$0 days 46-100
Outpatient Physical1, Occupational1, Speech Therapy
In-network: $30
Out-of-network: $75
Chiropractic Services
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
In-network: $20
Out-of-network: $40
Medicare-Covered Acupuncture
For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year
In-network: $40
Out-of-network: $75
Medicare-Covered Home Health Care Visits1
In-network: $0
Out-of-network: $15
Chemotherapy1
In-network: 20% of the cost
Out-of-network: 50% of the cost
Radiation Therapy1
Per service
In-network: 20% of the cost
Out-of-network: 25% 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.
In-network: $0
Out-of-network: $0
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.
In-network: $0 for up to a 90-day supply
Out-of-network: $0 for up to a 90-day supply
Diabetic Shoe Inserts
Copayment per pair
In-network: $10
Out-of-network: $30
Part B Insulin
One month supply
In-network: 20% of the cost, up to $35
Out-of-network: 50% of the cost
Non-Emergency Transportation
24 one-way trips to get to and from dialysis for members
diagnosed with end-stage renal disease (ESRD)
In-network: Covered
Out-of-network: Must use plan approved vendor
In-network: 20% of the cost
Out-of-network: 25% 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.
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.