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Plan Details
NetworkCares (PPO SNP)
Ideal for those who have both Medicare and Medicaid.
_Premium
$0 per month
Enroll Now- Prescription drug coverage
- $0 annual eye exam
- Comprehensive and preventive dental
- SilverSneakers® fitness
- Hearing aid discount benefit
- Transportation benefit
- $150 annual over-the-counter allowance
- Meal delivery after an inpatient hospital stay
- Bathroom safety adaptation reimbursement
- Regular contact from specialized care coordinators
- Wellness Rewards program to earn up to $75 in gift cards
Additional Benefits
Over-the-Counter Allowance
To keep you healthy and well, our NetworkCares members receive a $150 annual 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 hospital stay can be difficult. That’s why Network Health partners with Mom’s Meals to provide NetworkCares members with 14 delicious meals delivered right to your door after a qualifying inpatient hospital 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 12 one-way trips within the Network Health service area.
Bathroom Adaptation
NetworkCares offers a $300 annual reimbursement for approved bathroom home adaptation services and items. Contact the Network Health Concierge team for assistance with reimbursements.
Wellness Rewards
By completing three activities that are essential to your health and wellness, you can earn up to $75 in gift cards. It’s simply that easy to stay healthy.
- Receive a $25 gift card for your Annual Wellness Visit.
- Receive a $25 gift card for completing your annual Health Risk Assessment.
- Receive a $25 gift card 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 quick summary of what’s included and frequently asked questions, click here. Visit Delta Dental's website to Find a Dental Provider.
Vision
Annual eye exams are an important part of your health care, so we partner with EyeMed® to offer our NetworkCares members an annual routine eye 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.
Your Costs
NetworkCares (PPO SNP)
Services with a 1 may require prior authorization. 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.
Monthly Premium
$0
Annual Medical Deductible
In 2019 the amounts were:
$0-$185 depending on your level of Medicaid eligibility
These amounts may change for 2020.
$0-$185 depending on your level of Medicaid eligibility
These amounts may change for 2020.
Annual Maximum
Out-of-Pocket
Out-of-Pocket
$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 towards this limit
$10,000 for services you receive from any provider, your limit for services received from in-network providers will count towards this limit
Inpatient Hospital1
Per admission.
Per admission.
Annual Medical Deductible $0-$1,364
In 2019 the amounts were:
$0 per day, Days 1-60
$341 per day, Days 61-90
$682 per day, Days 91 and beyond
(this plan covers 60 lifetime reserve days)
These amounts may change for 2020.
In 2019 the amounts were:
$0 per day, Days 1-60
$341 per day, Days 61-90
$682 per day, Days 91 and beyond
(this plan covers 60 lifetime reserve days)
These amounts may change for 2020.
Outpatient Surgery1 Services
Including Ambulatory Surgical
Center Services such as
colonoscopies.
Including Ambulatory Surgical
Center Services such as
colonoscopies.
0%-20% of the cost
Primary Care Provider
0%-20% of the cost
Specialist
0%-20% of the cost
MDLIVE® Virtual
Doctor Visits
Doctor Visits
$0
Annual Medicare Wellness Visit
$0 in-network
0%-20% of the cost out-of-network
0%-20% of the cost out-of-network
Medicare Covered
Preventive Care
Preventive Care
$0 in-network
0%-20% of the cost out-of-network
0%-20% of the cost out-of-network
Medicare Covered
Immunizations
Flu, Pneumonia, Hepatitis B
Immunizations
Flu, Pneumonia, Hepatitis B
$0 in-network
0%-20% of the cost out-of-network
0%-20% of the cost out-of-network
Emergency Room
Your cost is waived if admitted to a U.S. hospital within 24 hours.
Your cost is waived if admitted to a U.S. hospital within 24 hours.
0%-20% of the cost, up to $90
$90 per incident
$100,000 Maximum Benefit
$100,000 Maximum Benefit
Urgent Care
0%-20% of the cost, up to $65
Ambulance
0%-20% of the cost
Ultrasound, EKG, EEG,
Stress Test
Stress Test
0%-20% of the cost
X-rays
0%-20% of the cost
Radiation Therapy1
Per service.
Per service.
0%-20% of the cost
Diagnostic Radiology
Services1
Such as MRIs, CT Scans.
Services1
Such as MRIs, CT Scans.
0%-20% of the cost
Medicare Covered
Hearing Exam
Hearing Exam
0%-20% of the cost
Routine Hearing Exam
Not covered
Hearing Aid Discount
Program
Includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Maximum of two hearing aids per year.
Program
Includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Maximum of two hearing aids per year.
Select hearing aids discounted to $1,220-$1,985 per device.
Save $775-$1,215 per hearing aid.
Save $775-$1,215 per hearing aid.
Medicare Covered
Dental Exam
Does not include services in connection with care, treatment, filling, removal or replacement of teeth.
Dental Exam
Does not include services in connection with care, treatment, filling, removal or replacement of teeth.
0%-20% of the cost
Additional dental benefits
$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
$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 Eye Exam
0%-20% of the cost
Medicare Covered Eyewear
0%-20% of the cost
Routine Eye Exam
One exam per year with an EyeMed provider.
One exam per year with an EyeMed provider.
$0 in-network, or
$40 reimbursement out-of-network
$40 reimbursement out-of-network
Non-Medicare Covered
Eyewear
Discounts offered at EyeMed providers.
Eyewear
Discounts offered at EyeMed providers.
$400 allowance in-network, or
$400 reimbursement out-of-network
$400 reimbursement out-of-network
Outpatient Individual or
Group Therapy, Psychiatric,
Telehealth
Group Therapy, Psychiatric,
Telehealth
0%-20% of the cost
Inpatient Mental Health1
Annual Medical Deductible $0-$1,364
In 2019 the amounts were:
$0 per day, Days 1-60
$0-$341 per day, Days 61-90
$0-$682 per day, Days 91 and beyond
(this plan covers 60 lifetime reserve days)
These amounts may change for 2020.
In 2019 the amounts were:
$0 per day, Days 1-60
$0-$341 per day, Days 61-90
$0-$682 per day, Days 91 and beyond
(this plan covers 60 lifetime reserve days)
These amounts may change for 2020.
Skilled Nursing Facility1
Per admission.
Per admission.
In 2019 the amounts were:
$0 per day, Days 1-20
$0-$170.50 per day, Days 21-100
A prior three-day inpatient hospital stay is required. These amounts may change for 2020.
$0 per day, Days 1-20
$0-$170.50 per day, Days 21-100
A prior three-day inpatient hospital stay is required. These amounts may change for 2020.
Physical, Occupational,
Speech Therapy
Includes comprehensive
outpatient rehabilitation facility.
Speech Therapy
Includes comprehensive
outpatient rehabilitation facility.
0%-20% of the cost
Cardiac and Pulmonary
Rehab
Maximum of 36 visits per year.
Rehab
Maximum of 36 visits per year.
0%-20% of the cost
Medicare Part B Drugs and Chemotherapy1
0%-20% of the cost
Medicare Part D Drugs
Covered - See prescription chart
Opioid Treatment Services
0%-20% of the cost
Lab and Clinical
Diagnostic Tests
Genetic/molecular testing requires authorization1
Diagnostic Tests
Genetic/molecular testing requires authorization1
0%-20% of the cost
Insulin Pumps1, CPAP
machines, Prosthetic
Devices1
machines, Prosthetic
Devices1
0%-20% of the cost
Diabetes Monitoring Supplies
and Test Strips
One TouchTM and Accu-ChekTM
All other brands are not covered.
and Test Strips
One TouchTM and Accu-ChekTM
All other brands are not covered.
0%-20% of the cost
Diabetic Shoe Inserts
0%-20% of the cost
Diabetes Self-Monitoring
Training
Training
0%-20% of the cost
Dialysis
For end stage renal disease
For end stage renal disease
0%-20% of the cost
Manipulation of the spine to
correct when one or more of
the bones of your spine move
out of position.
correct when one or more of
the bones of your spine move
out of position.
0%-20% of the cost
Medicare Covered Home
Health Care Visits1
Health Care Visits1
$0
Hospice covered by Medicare
$0
SilverSneakers® Fitness
Included
Caregiver Support
Included
Over-the-Counter Coverage
$150 per year
Meal Delivery
14 meals following a qualified inpatient hospital stay
Wellness Rewards
Earn up to $75 in gift cards by completing your annual health risk assessment, annual wellness visit and flu shot.
Non-Emergency
Transportation
Transportation
12 one-way trips, anywhere within the Network Health Medicare Plan service area
Bathroom Adaptation
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.
Your Drug Costs
NetworkCares (PPO SNP)
After you reach your yearly deductible of $0-$420 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 drugs1:
• In- and out-of-network: 0%-20% of the cost
Other Part B drugs1:
• In- and out-of-network: 0%-20% of the cost
Part D Prescription Drug Deductible on Tier 1
$0, Tiers 2-5: $420
• In- and out-of-network: 0%-20% of the cost
Other Part B drugs1:
• In- and out-of-network: 0%-20% of the cost
Part D Prescription Drug Deductible on Tier 1
$0, Tiers 2-5: $420
INITIAL COVERAGE
PREFERRED RETAIL
COST-SHARING
Tier
PREFERRED RETAIL
COST-SHARING
Tier
One-month supply
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
Three-month supply
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
Tier 1
(Preferred Generics)
(Preferred Generics)
• $0 copayment; or
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $4 or 15% of the cost
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $4 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $10 or 15% of the cost
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $10 or 15% of the cost
Tier 2
(Generics and
Non-Preferred Generics)
(Generics and
Non-Preferred Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $9 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $9 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $23 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $23 or 15% of the cost
Tier 3
(Non-Preferred
Generics and
Preferred Brands)
(Non-Preferred
Generics and
Preferred Brands)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $42 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $42 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $105 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $105 or 15% of the cost
Tier 4
(Non-Preferred Generics
and Non-Preferred Brands)
(Non-Preferred Generics
and Non-Preferred Brands)
• $0 copayment; or
• $1.30 copayment; or
•$3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $94 or 15% of the cost
• $1.30 copayment; or
•$3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $94 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
•$3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $235 or 15% of the cost
• $1.30 copayment; or
•$3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $235 or 15% of the cost
Tier 5
(Specialty)
(Specialty)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of 15% of the cost or 25% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of 15% of the cost or 25% of the cost
Not offered
INITIAL COVERAGE
STANDARD RETAIL
COST-SHARING
Tier
STANDARD RETAIL
COST-SHARING
Tier
One-month supply
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
Three-month supply
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
Tier 1
(Preferred
Generics)
(Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $6 or 15% of the cost
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $6 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $15; or 15% of the cost
• $1.30 copayment; or
•$3.60 copayment; or
lesser of $15; or 15% of the cost
Tier 2
(Generics and
Non-Preferred
Generics)
(Generics and
Non-Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $15 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $15 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $38 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment; or
lesser of $38 or 15% of the cost
Tier 3
(Non-
Preferred
Generics and
Preferred Brands)
(Non-
Preferred
Generics and
Preferred Brands)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $47 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $47 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $118 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $118 or 15% of the cost
Tier 4
(Non-Preferred
Generics and
Non-Preferred Brands)
(Non-Preferred
Generics and
Non-Preferred Brands)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $100 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $100 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $250 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $250 or 15% of the cost
Tier 5
(Specialty)
(Specialty)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of 15% of the cost or 25% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of 15% of the cost or 25% of the cost
Not offered
INITIAL COVERAGE
MAIL ORDER RETAIL
COST-SHARING
Tier
MAIL ORDER RETAIL
COST-SHARING
Tier
One-month supply
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
Three-month supply
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
Tier 1
(Preferred
Generics)
(Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
lesser of $4 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
lesser of $4 or 15% of the cost
• $0 copayment for 31-90 day mail order
Tier 2
(Generics and
Non-Preferred
Generics)
(Generics and
Non-Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
lesser of $9 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
lesser of $9 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
lesser of $23 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
lesser of $23 or 15% of the cost
Tier 3
(Non-Preferred
Generics and
Preferred
Brands)
(Non-Preferred
Generics and
Preferred
Brands)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $42 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $42 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copaymentt
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $105 or 15% of the cost
• $1.30 copayment; or
• $3.60 copaymentt
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $105 or 15% of the cost
Tier 4
(Non-Preferred
Generics and
Non-Preferred
Brands)
(Non-Preferred
Generics and
Non-Preferred
Brands)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $94 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $94 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $235 or 15% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of $235 or 15% of the cost
Tier 5
(Specialty)
(Specialty)
• $0 copayment; or
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of 15% of the cost or 25% of the cost
• $1.30 copayment; or
• $3.60 copayment
For all other drugs, either:
• $0 copayment; or
• $3.90 copayment; or
• $8.95 copayment; or
lesser of 15% of the cost or 25% 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 $6,350, you pay $0-$3.60 for drugs treated as generic and $0-$8.95 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.
