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Plan Details
NetworkCares (PPO D-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 per quarter over-the-counter allowance
- Meal delivery after a qualified inpatient stay
- Bathroom safety adaptation reimbursement
- Regular contact from specialized care coordinators
- Spark Wellness Rewards program earns up to $100 in rewards
Additional Benefits
Over-the-Counter Allowance
To keep you healthy and well, our NetworkCares members receive a $150 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 a gift card for your annual wellness visit.
- Receive a gift card for completing your annual health risk assessment.
- Receive a 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 D-SNP)
1Service may require prior authorization.
2Visitnetworkhealth.com/medicare/additional-benefits-snp for more information.
$0-$198 depending on your level of Medicaid eligibility.
These amounts may change for 2021.
Out-of-Pocket
(Does not include prescription drugs.)
$10,000 for services you receive from any provider, your limit for services received from in-network providers will count towards this limit
Per admission
In 2020 the amounts were:
$0 per day, Days 1-60
$0-$352 per day, Days 61-90
$0-$704 per day, Days 91 and beyond
(this plan covers 60 lifetime reserve days)
These amounts may change for 2021.
Such as diagnostic colonoscopies.
Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®
0%-20% of the cost out-of-network
0%-20% of the cost out-of-network
Such as flu, Pneumonia, Hepatitis B
0%-20% of the cost out-of-network
Copayment is waived if admitted to a U.S. hospital within 24 hours.
View theevidence of coverage for details.
$100,000 Maximum Benefit
Such as ultrasound, EKG, stress test
Per service.
Such as MRIs, CT Scans.
Exam to diagnose and treat hearing issues
Includes a three-year warranty with loss and damage insurance, up to six hearing aid follow up visits within three years and 16 batteries. Maximum of two hearing aids per year.
A savings of up to $1,050 per hearing aid.
Does not include services in connection with care, treatment, filling, removal or replacement of teeth.
$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
50% of the cost for major services (endodontics/periodontics/extractions, prosthodontics, other oral/maxillofacial surgery, other services)
$3,000 Annual Maximum
To diagnose and treat diseases and conditions of the eye
One exam per year.
$40 reimbursement out-of-network
Discounts offered at EyeMed providers.
$400 reimbursement out-of-network
Individual or group therapy
Per admission
In 2020 the amounts were:
$0 per day, Days 1-60
$0-$352 per day, Days 61-90
$0-$704 per day, Days 91 and beyond
(This plan covers 60 lifetime reserve days)
These amounts may change for 2021.
Per admission
$0 per day, Days 1-20
$0-$176 per day, Days 21-100
A prior three-day inpatient hospital stay is required. These amounts may change for 2021.
Includes comprehensive outpatient rehabilitation facility
See prescription drug chart for tier information
Counseling and therapy services provided by opioid treatment programs
0%-20% of the cost
Such as insulin pumps, CPAP machines, prosthetic devices
One TouchTM and Accu-ChekTMtest strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered.
Copayment per pair
Per treatment
Manipulation of the spine to correct misalignment of one or more of the bones of your spine.
Includes trips to medical and dental appointments, pharmacies, fitness centers, grocery stores, senior centers or local ADRC offices, health and wellness classes.
Your Drug Costs
Network Cares (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: $445
PREFERRED RETAIL
COST-SHARING
Tier
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
(Preferred Generics)
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $4 or 15% of the cost
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $10 or 15% of the cost
(Generics and
Non-Preferred Generics)
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $8 or 15% of the cost
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $20 or 15% of the cost
(Non- Preferred
Generics and
Preferred Brands)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $42 or 15% of the cost
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $105 or 15% of the cost
(Non- Preferred Generics
and Non-Preferred Brands)
• $1.30 copayment; or
•$3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $90 or 15% of the cost
• $1.30 copayment; or
•$3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $225 or 15% of the cost
(Specialty)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of 15% of the cost or 25% of the cost
STANDARD RETAIL
COST-SHARING
Tier
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
(Preferred
Generics)
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $6 or 15% of the cost
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $15; or 15% of the cost
(Generics and
Non-Preferred
Generics)
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $14 or 15% of the cost
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $35 or 15% of the cost
(Non-
Preferred
Generics and
Preferred Brands)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $47 or 15% of the cost
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $118 or 15% of the cost
(Non-Preferred
Generics and
Non-Preferred Brands)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $100 or 15% of the cost
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $250 or 15% of the cost
(Specialty)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of 15% of the cost or 25% of the cost
MAIL ORDER
COST-SHARING
Tier
For generic drugs (including
brand drugs treated as
generic), either:
For generic drugs (including
brand drugs treated as
generic), either:
(Preferred
Generics)
• $1.30 copayment; or
• $3.70 copayment; or
• lesser of $4 or 15% of the cost
(Generics and
Non-Preferred
Generics)
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $8 or 15% of the cost
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $20 or 15% of the cost
(Non-Preferred
Generics and
Preferred
Brands)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $42 or 15% of the cost
• $1.30 copayment; or
• $3.70 copaymentt
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $105 or 15% of the cost
(Non-Preferred
Generics and
Non-Preferred
Brands)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $90 or 15% of the cost
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of $225 or 15% of the cost
(Specialty)
• $1.30 copayment; or
• $3.70 copayment
For all other drugs, either:
• $0 copayment; or
• $4.00 copayment; or
• $9.20 copayment; or
lesser of 15% of the cost or 25% 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 $6,550, you pay $0-$3.70 for drugs treated as generic and $0-$9.20 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.
