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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- 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
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
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)
$0-$203 depending on your level of Medicaid eligibility. These amounts may change for 2022.
(Does not include Part D prescription drugs)
0%-20% of the cost out-of-network
0%-20% of the cost out-of-network
Flu, pneumonia, COVID-19
0%-0% of the cost out-of-network
Hepatitis B, all other Part B vaccines
0%-20% of the cost out-of-network
Per admission
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.
Such as ultrasound, EKG, stress test
Such as insulin pumps 1, CPAP machines, prosthetic devices 1
For medical (including dermatology) and mental health
View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details
$100,000
Maximum benefit
$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
Does not include services in connection with care, treatment, filling, removal or replacement of teeth
$40 reimbursement out-of-network
To diagnose and treat diseases and conditions of the eye
One pair of eyeglasses or contact lenses after each cataract surgery
$40 out-of-network
Maximum of two hearing aids per year
Hearing aid evaluation and fitting included
24 one-way trips, anywhere within the Network Health Medicare Advantage Plan service area
Following a hospital observation stay, qualified inpatient hospital stay, skilled nursing facility stay
Individual or group therapy
Per admission
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 individual or group therapy
Per admission
$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.
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year
Per service
Up to 12 visits per year are covered for members who are undergoing chemotherapy and experiencing nausea
One palliative care evaluation and two follow up visits
One Touch ™ and Accu-Chek ™ test strips, continuous glucose monitoring supplies limited to FreeStyle Libre ® and Dexcom ®. All other brands are not covered.
Copayment per pair
Per treatment
Your Drug Costs
NetworkCares (PPO D-SNP)
• 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
PREFERRED RETAIL
COST-SHARING
Tier
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
(Preferred Generics)
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $5 or 15% of the cost
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $12 or 15% of the cost
(Generics and
Non-Preferred Generics)
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $10 or 15% of the cost
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $25 or 15% of the cost
(Non-Preferred
Generics and
Preferred Brands)
• $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
• $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
• $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
• $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
(Specialty)
• $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
STANDARD RETAIL
COST-SHARING
Tier
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
(Preferred
Generics)
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $8 or 15% of the cost
• $1.35 copayment; or
•$3.95 copayment; or
lesser of $20 or 15% of the cost
(Generics and
Non-Preferred
Generics)
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $17 or 15% of the cost
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $42 or 15% of the cost
(Non-Preferred
Generics and
Preferred Brands)
• $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
• $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
• $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
• $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
(Specialty)
• $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
PREFERRED MAIL ORDER PHARMACY
COST-SHARING
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
For generic drugs (including brand drugs treated as generic) and brand drugs, either:
(Preferred
Generics)
• $1.35 copayment; or
• $3.95 copayment; or
• lesser of $5 or 15% of the cost
(Generics and
Non-Preferred
Generics)
• $1.35 copayment; or
• $3.95 copayment; or
lesser of $10 or 15% of the cost
(Non-Preferred
Generics and
Preferred
Brands)
• $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
• $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
• $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
• $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
(Specialty)
• $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
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.
