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Medicare Plans

Plan Details

Network PlatinumChoice (PPO)

Ideal for those who prefer low copayments and fitness benefits.

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Premium

$31 per month (includes pharmacy)

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  • Same costs for in- and out-of-network providers
  • $0 medical deductible
  • $0 copayment for 90-day mail order Tier 1 drugs
  • $10 copayment for primary care provider visits
  • $10 copayment for an in-network annual eye exam
  • $90 emergency room visit
  • $4,050 maximum out-of-pocket (combined in- and out-of-network)
  • 100% coverage for preventive care
  • Prescription drug coverage
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Hearing Aid discount benefit
  • Annual dental exam and cleaning

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumChoice (PPO)

1Service may require prior authorization.
2Visit networkhealth.com/medicare/additional-benefits for more information.

Monthly Premium
$31
Annual Medical Deductible
$0
Annual Maximum Out-of-Pocket

(Combined In- and Out-of-Network) (Does not include prescription drugs)

$4,050
Inpatient Hospital1

Per admission

$400 per day, Days 1-5 $0 Days 6 and beyond
Outpatient Surgery Services
$395
Primary Care Provider Visit
$10
Specialist Visit
$50
Preventive Care
$0
Medicare-Covered Dental Services
$50
Emergency Room Visit

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

$90
Urgent Care
$50
Diagnostic Lab Tests
$0-$15
X-rays
$30
Diagnostic Tests

Such as ultrasound, EKG, stress test

$35
Radiation Therapy1

Per service

20% of the cost
Diagnostic Radiology Services1

Such as MRIs, CT scans

$200
Outpatient Ambulatory Surgical Center Services

Such as diagnostic colonoscopies

$395
Preventive Dental Exam2

One exam and cleaning per year, X-rays are not included

$30 in-network

$100 reimbursement out-of-network

Comprehensive Dental Benefit2
$38 monthly premium Annual Maximum: $1,000
Routine Eye Exam2

One exam per year

$10 in-network, $40 reimbursement out-of-network 
Diagnostic Eye Exam

$50

Inpatient Mental Health1

Per admission

$295 per day, Days 1-4 $0 Days 5 and beyond
Outpatient Mental Health

Individual or group therapy

$40
Skilled Nursing Facility1

Per admission

$0 per day, Days 1-20 $184 per day, Days 21-49 $0 Days 50-100
Physical, Occupational, Speech Outpatient Therapy

Includes comprehensive outpatient rehabilitation facility

$40
Ambulance - Air and Ground Services
$275
Transportation - Non-Emergency

Includes 24 one-way trips for all members diagnosed with end stage renal disease (ERSD), to get to and from dialysis for treatment

Covered
Medicare Part B Drugs and Chemotherapy1
20% of the cost
Medicare Part D Drugs

See prescription drug chart for tier information

Covered
Chiropractic Services

Manipulation of the spine to correct misalignment of one or more of the bones of your spine

$20
Diabetes Monitoring Supplies and Test Strips1

OneTouchTM and Accu-ChekTM test strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered.

$0 for up to a 90-day supply
Dialysis

Per treatment

20% of the cost

Diabetic Shoe Inserts

Copayment per pair

$10
Durable Medical Equipment

Such as insulin pumps, CPAP machines, prosthetic devices1

20% of the cost
Medicare-Covered Home Health Care Visits1
$0
Virtual Visits2

Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®2

$0
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)
Additional Eyewear2

Discounts offered at EyeMed providers

Discounts included
SilverSneakers® Fitness2
Included
Over-the-Counter Coverage2

No rollover on quarterly allowance

Not included
Pick Your Perks Reimbursement Program2

Reimbursement for Medicare-approved supplemental benefits including dental, vision, meals, non-emergency transportation, over-the-counter items, acupuncture, massage thereapy expenses and nutritional/dietary benefits2

Not included

Network PlatinumChoice (PPO)

When your coverage starts, you have $0 a deductible for Tiers 1-3
Drug Deductible
$260 for Tiers 4 and 5 only
Initial Coverage

30-Day Supply Preferred Pharmacy
or Mail Order Pharmacy
$2 for Tier 1     $42 for Tier 3
$8 for Tier 2     $90 for Tier 4
28% of the cost for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1       $47 for Tier 3
$14 for Tier 2     $100 for Tier 4
28% of the cost for Tier 5

90-Day Supply Preferred Pharmacy
$5 for Tier 1       $105 for Tier 3
$20 for Tier 2     $225 for Tier 4
Tier 5 is not available

90-Day Supply Standard Pharmacy
$10 for Tier 1     $118 for Tier 3
$35 for Tier 2     $250 for Tier 4
Tier 5 is not available

31 to 90-Day Supply Mail Order Pharmacy
$0 for Tier 1

90-Day Supply Mail Order Pharmacy
$0 for Tier 1       $105 for Tier 3
$20 for Tier 2     $225 for Tier 4
Tier 5 is not available

Coverage Gap
You enter the coverage gap when total drug costs reach $4,130. You pay 25% and Network Health pays 75% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.
Catastrophic Coverage
You enter catastrophic coverage when your true out-of-pocket costs reach $6,550. You pay the greater of $3.70 or 5% of the cost for generic drugs and $9.20 or 5% of the cost for brand name drugs.

This information is not a complete description of benefits. Call 800-378-5234 (TTY 800-947-3529) for more information. 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.