For information on the coronavirus vaccine and your benefits as a Network Health member, click here.

Medicare Plans

Plan Details

NetworkCares (PPO D-SNP)

Medical and pharmacy coverage for people who have both Medicare and Medicaid benefits.

_

Premium

$0 a month

Enroll Now
Enroll Now
  • You pay the same in- and out-of-network for medical benefits (unless specified)
  • $0 copayment for an annual routine hearing exam
  • $100 in health rewards with the Spark Wellness Program
  • $155 quarterly over-the-counter benefit
  • $400 allowance for glasses and contacts
  • SilverSneakers® fitness
  • Transportation benefit
  • Same costs for in- and out-of-network providers
  • Must qualify for Medicaid to enroll in this plan
  • $0 monthly premium
  • $0 copayment for mail order Tier 1 drugs at a preferred mail order pharmacy. $0 copayment for mail order Tier 2 drugs after deductible at a preferred mail order pharmacy.
  • 100% coverage for preventive care
  • Comprehensive and preventive dental
  • $0 annual routine hearing exam
  • $300 Bathroom safety adaptation reimbursement
  • Meal delivery after an inpatient or skilled nursing facility stay
  • Regular contact from specialized care coordinators

Additional Benefits

Over-the-Counter Allowance

To keep you healthy and well, our NetworkCares members receive a $155 per quarter over-the-counter allowance. Hundreds of useful items can be mailed directly to your home at no cost to you.

Meals

Recovering after an inpatient stay can be difficult. That’s why Network Health partners with Mom’s Meals to provide NetworkCares members with 28 delicious meals delivered right to your door after a qualifying inpatient hospital stay, a hospital observation or a skilled nursing facility stay.

Transportation

Need a ride to the dentist or to the doctor? We can help. Our partnership with Aryv helps you get to where you need to be, safely. The transportation benefit includes 24 one-way trips within the Network Health service area. Also includes 24 one-way trips for all members diagnosed with ESRD to get to and from dialysis for treatment.

Bathroom Adaptation

NetworkCares offers a $300 annual reimbursement for approved bathroom home adaptation services and items. Contact the member experience team for assistance with reimbursements.

Wellness Rewards

By completing three activities that are essential to your health and wellness, you can earn up to $100 in rewards. It’s simply that easy to stay healthy.

  • Receive health rewards for your annual wellness visit.
  • Receive health rewards for completing your annual health risk assessment.
  • Receive health rewards for your flu shot.

Dental

Dental

Protecting your teeth and gums should be as routine as your annual wellness visit. Network Health partners with Delta Dental® Medicare Advantage to offer NetworkCares members preventive and comprehensive dental care. For a summary of what's included and frequently asked questions, click here. Visit Delta Dental's website to Find a Dental Provider.

Vision

Vision

Annual vision exams are an important part of your health care, so we partner with EyeMed® to offer our NetworkCares members an annual routine vision exam for a $0 copayment and up to $400 for eyewear. For a summary of what’s included and frequently asked questions, click here. Visit EyeMed's website to Find a Vision Provider.

Dual-Eligible Special Needs PPO Plan Benefits

Network Cares (PPO D-SNP)

Monthly Premium
$0
Annual Medical Deductible
In 2021 the amounts were:
$0-$203 depending on your level of Medicaid eligibility. These amounts may change for 2022.
Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

$6,700 for services you receive from in-network providers $10,000 for services you receive from any provider, your limit for services received from in-network providers will count toward this limit
Primary Care Provider Visit
0%-20% of the cost
Specialist Visit
0%-20% of the cost
Preventive Care*
$0 in-network
0%-20% of the cost out-of-network
Annual Medicare Wellness Visit
$0 in-network
0%-20% of the cost out-of-network
Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

$0 in-network
0%-0% of the cost out-of-network
Medicare-Covered Vaccines

Hepatitis B, all other Part B vaccines

$0 in-network
0%-20% of the cost out-of-network
Inpatient Hospital Services 1

Per admission

Annual Medical Deductible $0-$1,484
In 2021 the amounts were:
$0 per day, Days 1-60
$0-$371 per day, Days 61-90
$0-$742 per day, Days 91 and beyond
(This plan covers 60 lifetime reserve days) These amounts may change for 2022.
Outpatient Hospital Services
0%-20% of the cost
Labs
0%-20% of the cost
Diagnostic Tests

Such as ultrasound, EKG, stress test

0%-20% of the cost
X-rays
0%-20% of the cost
Diagnostic Radiology Services– Advanced Imaging
0%-20% of the cost
Urgent Care Visit
0%-20% of the cost, up to $65
Emergency Room Visit
0%-20% of the cost, up to $90
Air and Ground Ambulance Services
0%-20% of the cost
Durable Medical Equipment

Such as insulin pumps 1, CPAP machines, prosthetic devices 1

0%-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 (including dermatology) and mental health

$0
Medicare Part B Drugs 1
0%-20% of the cost
Travel within the United States
Receive in-network coverage when you see a provider outside Wisconsin, anywhere in the United States
International Emergency Coverage

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

$90 per incident
$100,000
Maximum benefit
Preventive Dental Services 2
$0 Cleaning (twice a year)
$0 Dental X-ray(s) (bitewing 1 per year, full mouth 1 every 5 years)
$0 Oral exam (twice a year)
$0 Basic restorative services
0%-50% of the cost for major services (endodontics/periodontics/extractions, prosthodontics, other oral/maxillofacial surgery, other services)
$3,000 annual maximum
Medicare-Covered Dental Services

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

0%-20% of the cost
Annual Routine Vision Exam 2
$0 in-network, or
$40 reimbursement out-of-network
Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

0%-20% of the cost
Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

0%-20% of the cost
Over-the-Counter Coverage 2
$155 per quarter
Fitness with SilverSneakers ® 2
Included
Routine Hearing Exam 2
$0 in-network, or
$40 out-of-network
Diagnostic Hearing Exam
0%-20% of the cost
Hearing Aids 2

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

$679-$2,299 per device
Non-Emergency Transportation

24 one-way trips, anywhere within the Network Health Medicare Advantage Plan service area

Additionally includes 24 one-way trips for members with ESRD to get to and from dialysis
Meal Delivery

Following a hospital observation stay, qualified inpatient hospital stay, skilled nursing facility stay

28 meals
Wellness Rewards 2
Earn up to $100 in rewards by completing your annual health risk assessment, annual wellness visit and flu shot.
Bathroom Adaptation 2
With proper documentation, which includes a completed NetworkCares Bathroom Adaptation Reimbursement Form and attached itemized receipts and invoices detailing the cost of the bathroom adaptation services/items purchased, the plan will reimburse the paid amount or up to the maximum benefit of $300 each year for approved bathroom home adaptation services/items.
Outpatient Mental Health

Individual or group therapy

0%-20% of the cost
Inpatient Mental Health 1

Per admission

Annual Medical Deductible $0-$1,484
In 2021 the amounts were:
$0 per day, Days 1-60
$0-$371 per day, Days 61-90
$0-$742 per day, Days 91 and beyond
(This plan covers 60 lifetime reserve days) These amounts may change for 2022.
Opioid Treatment Services
0%-20% of the cost
Substance Abuse Services

Outpatient individual or group therapy

0%-20% of the cost
Skilled Nursing Facility 1

Per admission

In 2021 the amounts were:
$0 per day, Days 1-20
$0-$185.50 per day, Days 21-100
A prior three-day inpatient hospital stay is required. These amounts may change for 2022.
Outpatient Physical 1, Occupational 1, Speech Therapy
0%-20% of the cost
Chiropractic Services

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

0%-20% of the cost
Medicare-Covered Acupuncture

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

0%-20% of the cost
Medicare-Covered Home Health Care Visits 1
$0
Chemotherapy 1
0%-20% of the cost
Radiation Therapy 1

Per service

0%-20% of the cost
Acupuncture

Up to 12 visits per year are covered for members who are undergoing chemotherapy and experiencing nausea

$0
Home-Based Palliative Care

One palliative care evaluation and two follow up visits

$0
Diabetes Monitoring Supplies and Test Strips

One Touch and Accu-Chek test strips, continuous glucose monitoring supplies limited to FreeStyle Libre ® and Dexcom ®. All other brands are not covered.

0%-20% of the cost
Diabetic Shoe Inserts

Copayment per pair

0%-20% of the cost
Diabetes Management Tool
$0
Dialysis

Per treatment

0%-20% of the cost
1 Service may require prior authorization.
2 Visit networkhealth.com/medicare/additional-benefits for more information.
Because covered services and copayments could change, you should ask your provider what your copayment amount will be. If you get more than one service during the same appointment, you may be asked for more than one copayment.

 Your Drug Costs

NetworkCares (PPO D-SNP)

After you reach your yearly deductible of $0-$480 for your Tier 2-5 drugs, you pay the following copayments or coinsurance for your drugs. You will need to fill your prescriptions at in-network retail pharmacies or the plan’s mail order pharmacy.
How much do I pay? 
For Part B drugs such as chemotherapy drugs 1:
• In- and out-of-network: 0%-20% of the cost
Other Part B drugs 1:
• In- and out-of-network: 0%-20% of the cost
Part D Prescription Drug Deductible on Tier 1
$0, Tiers 2-5: $480
INITIAL COVERAGE
PREFERRED RETAIL
COST-SHARING
Tier
One-month supply
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
Three-month supply
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
Tier 1
(Preferred Generics)
• $0 copayment; or
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $5 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $12 or 15% of the cost
Tier 2
(Generics and
Non-Preferred Generics)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $10 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $25 or 15% of the cost
Tier 3
(Non-Preferred
Generics and
Preferred Brands)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $42 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $105 or 15% of the cost
Tier 4 (Non-Preferred Drugs)
• $0 copayment; or
• $1.35 copayment; or
•$3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $95 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
•$3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $237 or 15% of the cost
Tier 5
(Specialty)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
15% of the cost
Not offered
INITIAL COVERAGE
STANDARD RETAIL
COST-SHARING
Tier
One-month supply
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
Three-month supply
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
Tier 1
(Preferred
Generics)
• $0 copayment; or
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $8 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $20 or 15% of the cost
Tier 2
(Generics and
Non-Preferred
Generics)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $17 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $42 or 15% of the cost
Tier 3
(Non-Preferred
Generics and
Preferred Brands)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $47 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $117 or 15% of the cost
Tier 4 (Non-Preferred Drugs)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $100 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $250 or 15% of the cost
Tier 5
(Specialty)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
15% of the cost
Not offered
INITIAL COVERAGE
PREFERRED MAIL ORDER PHARMACY
COST-SHARING
One-month supply
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
Three-month supply
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
Tier 1
(Preferred
Generics)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment; or
• lesser of $5 or 15% of the cost
• $0 copayment for 31-90 day mail order
Tier 2
(Generics and
Non-Preferred
Generics)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $10 or 15% of the cost
• $0 copayment for 31-90 day preferred mail order after deductible
Tier 3
(Non-Preferred
Generics and
Preferred
Brands)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $42 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copaymentt
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $105 or 15% of the cost
Tier 4 (Non-Preferred Drugs)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $95 or 15% of the cost
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
lesser of $237 or 15% of the cost
Tier 5
(Specialty)
• $0 copayment; or
• $1.35 copayment; or
• $3.95 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.85 copayment; or
15% of the cost
Not offered

 

CATASTROPHIC COVERAGE
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050, you pay $0-$3.95 for drugs treated as generic and $0-$9.85 for drugs treated as brand.

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.


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.