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Medicare Plans

Plan Details

NetworkCares (PPO D-SNP)

Ideal for those who have both Medicare and Medicaid.

_

Premium

$0 per month

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  • 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

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

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.

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 2020 the amounts were:
$0-$198 depending on your level of Medicaid eligibility.
These amounts may change for 2021.
Annual Maximum
Out-of-Pocket

(Does not include 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 towards this limit
Inpatient Hospital1

Per admission

Annual Medical Deductible $0-$1,408
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.
Outpatient Ambulatory Surgical Center Services

Such as diagnostic colonoscopies.

0%-20% of the cost
Primary Care Provider Visit
0%-20% of the cost
Specialist Visit 
0%-20% of the cost
Virtual Visit2

Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®

$0
Preventive Annual Medicare Wellness Visit 
$0 in-network
0%-20% of the cost out-of-network
Preventive Care
$0 in-network
0%-20% of the cost out-of-network
Preventive Medicare-Covered Vaccines

Such as flu, Pneumonia, Hepatitis B

$0 in-network
0%-20% of the cost out-of-network
Emergency Room Visit

Copayment is waived if admitted to a U.S. hospital within 24 hours.

0%-20% of the cost, up to $90
International Emergency Coverage

View theevidence of coverage for details.

$90 per incident
$100,000 Maximum Benefit
Urgent Care
0%-20% of the cost, up to $65
Ambulance - Air and Ground Services
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
Radiation Therapy1

Per service.

0%-20% of the cost
Diagnostic Radiology Services1

Such as MRIs, CT Scans.

0%-20% of the cost
Diagnostic Hearing Exam

Exam to diagnose and treat hearing issues

0%-20% of the cost
Routine Hearing Exam
Not covered
Hearing Aids2
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.
Select hearing aids discounted to $795-$2,370 per device.
A savings of up to $1,050 per hearing aid.
Medicare Covered Dental Services

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

0%-20% of the cost
Comprehensive Dental Benefit2
$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
50% of the cost for major services (endodontics/periodontics/extractions, prosthodontics, other oral/maxillofacial surgery, other services)
$3,000 Annual Maximum
Diagnostic Covered Eye Exam

To diagnose and treat diseases and conditions of the eye

0%-20% of the cost
Routine Eye Exam2

One exam per year.

$0 in-network, or
$40 reimbursement out-of-network
Additional Eyewear2

Discounts offered at EyeMed providers.

$400 allowance in-network, or
$400 reimbursement out-of-network
Outpatient Mental Health

Individual or group therapy

0%-20% of the cost
Inpatient Mental Health1

Per admission

Annual Medical Deductible $0-$1,408
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.
Skilled Nursing Facility1

Per admission

In 2020 the amounts were:
$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.
Physical, Occupational, Speech Outpatient Therapy
Includes comprehensive outpatient rehabilitation facility
0%-20% of the cost
Medicare Part B Drugs and Chemotherapy1
0%-20% of the cost
Medicare Part D Drugs

See prescription drug chart for tier information

Covered
Opioid Treatment Services

Counseling and therapy services provided by opioid treatment programs

0%-20% of the cost
Diagnostic Lab Tests

0%-20% of the cost

Durable Medical Equipment1

Such as insulin pumps, CPAP machines, prosthetic devices

0%-20% of the cost
Diabetes Monitoring Supplies and Test Strips

One TouchTM and Accu-ChekTMtest 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
Dialysis

Per treatment

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 Home Health Care Visits1
$0
SilverSneakers® Fitness2
Included
Over-the-Counter Coverage2
$150 per quarter
Meal Delivery
28 meals following a qualified inpatient hospital, hospital observation or skilled nursing facility stay
Spark Wellness Program2
Earn up to $100 in gift cards by completing your annual health risk assessment ($50), annual wellness visit ($25) and flu shot ($25).
Non-Emergency Transportation

Includes trips to medical and dental appointments, pharmacies, fitness centers, grocery stores, senior centers or local ADRC offices, health and wellness classes.

24 one-way trips, anywhere within the Network Health Medicare Plan service area. Additionally includes 24 one-way trips for all members diagnosed with ESRD to get to and from dialysis for treatment. 
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

Network Cares (PPO D-SNP)

After you reach your yearly deductible of $0-$445 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: $445
INITIAL COVERAGE
PREFERRED RETAIL
COST-SHARING
Tier 
One-month supply
For generic drugs (including
brand drugs 
treated as
generic), either:
Three-month supply
For generic drugs (including
brand drugs treated as
generic), either:
Tier 1
(Preferred  Generics)
• $0 copayment; or
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $4 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $10 or 15% of the cost
Tier 2
(Generics and
Non-Preferred  Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $8 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $20 or 15% of the cost
Tier 3
(Non- Preferred
Generics and
Preferred Brands)
• $0 copayment; or
• $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
• $0 copayment; or
• $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
Tier 4
(Non- Preferred  Generics
and Non-Preferred Brands)
• $0 copayment; or
• $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
• $0 copayment; or
• $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
Tier 5
(Specialty)
• $0 copayment; or
• $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
Not offered
INITIAL COVERAGE
STANDARD RETAIL
COST-SHARING

Tier
One-month supply
For generic drugs (including
brand drugs 
treated as
generic), either:
Three-month supply
For generic drugs (including
brand drugs treated as
generic), either:
Tier 1
(Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $6 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
•$3.70 copayment; or
lesser of $15; or 15% of the cost
Tier 2
(Generics and
Non-Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $14 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $35 or 15% of the cost
Tier 3
(Non-
Preferred
Generics and
Preferred Brands)
• $0 copayment; or
• $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
• $0 copayment; or
• $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
Tier 4
(Non-Preferred
Generics and
Non-Preferred Brands)
• $0 copayment; or
• $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
• $0 copayment; or
• $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
Tier 5
(Specialty)
• $0 copayment; or
• $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
Not offered
INITIAL COVERAGE
MAIL
ORDER  
COST-SHARING

Tier
One-month supply
For generic drugs (including
brand drugs 
treated as
generic), either:
Three-month supply
For generic drugs (including
brand drugs treated as
generic), either:
Tier 1
(Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.70 copayment; or
• lesser of $4 or 15% of the cost
• $0 copayment for 31-90 day mail order
Tier 2
(Generics and
Non-Preferred
Generics)
• $0 copayment; or
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $8 or 15% of the cost
• $0 copayment; or
• $1.30 copayment; or
• $3.70 copayment; or
lesser of $20 or 15% of the cost
Tier 3
(Non-Preferred
Generics and
Preferred
Brands)
• $0 copayment; or
• $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
• $0 copayment; or
• $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
Tier 4
(Non-Preferred
Generics and
Non-Preferred
Brands)
• $0 copayment; or
• $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
• $0 copayment; or
• $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
Tier 5
(Specialty)
• $0 copayment; or
• $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
Not offered

 

CATASTROPHIC COVERAGE
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, 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.


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.