Northeast Medicare Advantage PPO Plan Benefits
Network Health Choice (PPO)
Monthly Part B Premium Giveback2
Must be enrolled in Medicare Parts A and B, pay own premiums and live in a service area that offers this benefit.
N/A
Annual Medical Deductible
$500
Annual Maximum Out-of-Pocket
(Does not include Part D prescription drugs)
$5,100 combined in- and out-of-network
Primary Care Provider Visit
$0
Deductible applies out-of-network
Specialist Visit
$50
Deductible applies out-of-network
Annual Medicare Wellness Visit
$0
Medicare-Covered Vaccines
Flu, pneumonia, COVID-19
$0
Part B Vaccines
Hepatitis B1, all other Part B vaccines
$0
Inpatient Hospital Services1
Per admission
$340 per day, days 1-7
$0 days 8-90
Deductible applies
Outpatient Hospital Services1
$0-$300
Deductible applies
Ambulatory Surgical Center1
$0-$200
Deductible applies out-of-network
Labs
$0 or $40
Deductible applies out-of-network
Diagnostic Tests1
Such as ultrasound, EKG, stress test
$90
Deductible applies
X-rays
$90
Deductible applies
Diagnostic Radiology Services– Advanced Imaging1
$295
Deductible applies
Diagnostic Mammogram
$0
Deductible applies out-of-network
Urgent Care Visit
Free-standing facility
$50
Emergency Room Visit
Copayment is waived if admitted to a U.S. hospital within 24 hours
$130
Air and Ground Ambulance Services
$275
Deductible applies out-of-network
Durable Medical Equipment
Such as insulin pumps1, CPAP machines, prosthetic devices1
20% of the allowed amount
Deductible applies
Durable Medical Equipment for Home Infusion
Medical supplies
0% coinsurance
Deductible applies out-of-network
Physician Telehealth Services
Virtual primary care and urgent care services cost the same as an in-person visit
Deductible applies out-of-network
Virtual Visit with MDLIVE®2
For medical services
$0
Deductible applies out-of-network
Medicare Part B Drugs1
20% of the cost
Deductible applies
Medicare Part D Drugs1
Covered
Travel within the United States
Receive in-network coverage when you venture outside Wisconsin and within the United States territories. You can see any provider who accepts Medicare beneficiaries.
$130 per incident
$100,000
Maximum benefit
Pick Your Perks2
Not available
Dental Services2
100% coverage for preventive
50% coverage for comprehensive
$1,000 combined annual maximum
Out-of-network: Member pays 80% of the allowed amount
Out-of-network dentists do not have a contract with Say Cheese Dental Network, so they have not agreed to a contracted price or payment amount for dental services. Additionally, out-of-network dentists can balance bill you the difference between the charges they bill for their services and Say Cheese Dental Network’s allowed payment amount.
Medicare-Covered Dental Services
Does not include services in connection with care, treatment, filling, removal or replacement of teeth
$50
Deductible applies out-of-network
Optional Comprehensive Dental Coverage2
Not available
Annual Routine Vision Exam2
In-Network: $10
Out-of-Network: Up to $40 reimbursement out-of-network
Diagnostic Eye Exam
To diagnose and treat diseases and conditions of the eye
$50
Deductible applies out-of-network
Post-Cataract Eyewear
One pair of eyeglasses or contact lenses after each cataract surgery
$0
Deductible applies out-of-network
Fitness with One Pass™2
In-Network: $0
Routine Hearing Exam2
In-Network: $0
Diagnostic Hearing Exam
Exam to diagnose and treat hearing issues
$50
Deductible applies out-of-network
Fitting/Evaluation for Hearing Aids2
In-Network: $0
Hearing Aids2
Maximum of two hearing aids per year
Hearing aid evaluation with TruHearing and fitting included
In-Network: $495-$1,695 per device
Outpatient Mental Health
Individual or group therapy
$50
Deductible applies out-of-network
Inpatient Mental Health1
Per admission
$295 per day, days 1-4
$0 days 5 and beyond
Deductible applies
Opioid Treatment Services
$50
Deductible applies out-of-network
Substance Abuse Services
Outpatient individual or group therapy
$50
Deductible applies out-of-network
Skilled Nursing Facility1
Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day
$0 per day, days 1-20
$221 per day, days 21-45
$0 days 46-100
Deductible applies
Outpatient Physical1, Occupational1, Speech Therapy
$50
Deductible applies
Medicare-Covered Chiropractic Services
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
$15
Deductible applies out-of-network
Medicare-Covered Acupuncture
For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year
$50
Deductible applies out-of-network
Medicare-Covered Home Health Care Visits1
$0
Deductible applies
Chemotherapy1
20% of the allowed amount
Deductible applies
Radiation Therapy1
20% of the allowed amount
Deductible applies
Diabetes Monitoring Supplies and Test Strips
Accu-Chek™ and FreeStyle™ test strips
FreeStyle Libre® and Dexcom® continuous glucose monitoring devices and supplies1 obtained through your pharmacy. Must have diabetic diagnosis. All other brands not covered.
Deductible applies out-of-network.
$0 for up to a 90-day supply
Deductible applies out-of-network
Part B Insulin1
One month supply
No more than $35
Diabetic Shoe Inserts
Copayment per pair
$10
Deductible applies
20% of the allowed amount
Deductible applies
*Includes abdominal aortic aneurysm screening, alcohol misuse screening and counseling, annual wellness visit, bone mass measurement, breast cancer screening, cardiovascular disease screening, cardiovascular disease risk reduction visit, cervical and vaginal cancer screening, colorectal cancer screening (screening colonoscopy, fecal occult blood test, flexible sigmoidoscopy), depression screening, diabetes screening, glaucoma screening, HIV screening, lung cancer screening, medical nutrition therapy services, Medicare Diabetes Prevention Program, obesity screening and therapy, prostate cancer screening, screening for sexually transmitted infections and counseling, smoking and tobacco use cessation counseling, one time Welcome to Medicare preventive visit
1Service may require prior authorization.