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Medicare Plans

Plan Details

Network PlatinumChoice (PPO)

Ideal for those who prefer to pay a small monthly premium and have lower copayments.

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Premium

$31

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  • Same costs for in-and out-of-network providers
  • Medical and pharmacy coverage with a $31 monthly premium
  • Annual maximum out-of-pocket of $4,150
  • SilverSneakers® Fitness benefit
  • $0 medical deductible
  • $0 copayment for personal doctor (primary care provider) visits
  • Dental benefit includes two cleanings, exams and one x-ray per year for $0
  • $0 copayment for mail order Tier 1 and 2 drugs at a preferred mail order pharmacy
  • $0 pharmacy deductible on Tiers 1, 2 and 3
  • $25 quarterly over-the-counter benefit
  • $0 copayment for an annual routine hearing exam
  • 100% coverage for preventive care
  • Travel coverage

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumChoice (PPO)

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

(Does not include Part D prescription drugs)

$4,150 Combined in- and out-of-network
Primary Care Provider Visit
$0
Specialist Visit
$45
Preventive Care*
$0
Annual Medicare Wellness Visit
$0
Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

$0
Part B Vaccines

Hepatitis B, all other Part B vaccines

$0
Inpatient Hospital Services1

Per admission

$315 per day, Days 1-7
$0 Days 8 and beyond
Outpatient Hospital Services
$300
$200 at an ambulatory surgical center
Labs
$0-$10
Diagnostic Tests

Such as ultrasound, EKG, stress test

$35
X-rays
$30
Diagnostic Radiology Services– Advanced Imaging
$125
Urgent Care Visit
$45
Emergency Room Visit

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

$90
Air and Ground Ambulance Services
$275
Durable Medical Equipment

Such as insulin pumps1, CPAP machines, prosthetic devices1

20% of the cost
Physician Telehealth Services
Virtual primary care and urgent care services cost the same as an in-person visit
Virtual Visit with MDLIVE®2

For medical (including dermatology) and mental health

$0
Medicare Part B Drugs1
20% of the cost
Travel within the United States
Receive in-network coverage when you see a provider outside Wisconsin, anywhere in the United States
International Emergency Coverage

View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details

$90 per incident
$100,000
Maximum benefit
Pick Your Perks2

Reimbursement for the following extra benefits: dental services, vision hardware, healthy home-delivered meals, non-emergency transportation, over-the-counter items, acupuncture, massage therapy, personal training (four visits or $225 maximum, whichever happens first), nutritional/dietary counseling

Not Included
Preventive Dental Services2
In-Network: 2 cleanings and exams per year for $0
In-Network: 1 bitewing x-ray per year for $0
Out-of-Network: $100 reimbursement
Medicare-Covered Dental Services

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

$45
Optional Comprehensive Dental Coverage2
$39 monthly premium
Annual Maximum: $1,000
Annual Routine Vision Exam2
In-Network: $10
Out-of-Network: $40 reimbursement
Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

$45
Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

$0
Over-the-Counter Coverage2
$25 per quarter
No rollover on quarterly allowance
Fitness with SilverSneakers®2
Included
Routine Hearing Exam2
In-Network: $0
Out-of-Network: $40
Diagnostic Hearing Exam
$45
Hearing Aids2

Maximum of two hearing aids per year
Hearing aid evaluation and fitting included

$679-$2,299 per device
Outpatient Mental Health

Individual or group therapy

$40
Inpatient Mental Health1

Per admission

$295 per day, Days 1-4
$0 Days 5 and beyond
Opioid Treatment Services
$40
Substance Abuse Services

Outpatient individual or group therapy

$40
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
$188 per day, Days 21-45
$0 Days 46-100
Outpatient Physical1, Occupational1, Speech Therapy
$40
Chiropractic Services

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

$20
Medicare-Covered Acupuncture

For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year

$45
Medicare-Covered Home Health Care Visits1
$0
Chemotherapy1
20% of the cost
Radiation Therapy1
20% of the cost
Acupuncture

Up to 12 visits per year are covered for members who are undergoing chemotherapy and experiencing nausea

$0
Home-Based Palliative Care
One palliative care evaluation and two follow up visits
Diabetes Monitoring Supplies and Test Strips

One Touch and Accu-Chek 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
Diabetic Shoe Inserts

Copayment per pair

$10
Non-Emergency Transportation

24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)

Covered
Dialysis
20% of the cost
*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.

Network PlatinumChoice (PPO) Drug Plan Costs

Annual Drug Deductible
$260 Applies to Tiers 4-5
INITIAL COVERAGE Amount shown is the maximum you will pay, you may pay less.

30-Day Supply
Preferred Pharmacy or Preferred Mail Order Pharmacy

$2 for Tier 1
$8 for Tier 2
$42 for Tier 3
$95 for Tier 4
28% of the cost for Tier 5

90-Day Supply
Preferred Pharmacy

$5 for Tier 1
$20 for Tier 2
$105 for Tier 3
$237 for Tier 4
Tier 5 is not available

31 to 90-Day Supply
Preferred Mail Order Pharmacy

$0 for Tier 1
$0 for Tier 2

90-Day Supply
Preferred Mail Order Pharmacy

$0 for Tier 1
$0 for Tier 2
$105 for Tier 3
$237 for Tier 4
Tier 5 is not available

30-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy

$5 for Tier 1
$15 for Tier 2
$47 for Tier 3
$100 for Tier 4
28% of the cost for Tier 5

90-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy

$12 for Tier 1
$37 for Tier 2
$117 for Tier 3
$250 for Tier 4
Tier 5 is not available

Coverage Gap
You enter the coverage gap when your total drug costs reach $4,430. 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 $7,050. You pay the greater of $3.95 or 5% of the cost for generic drugs and the greater of $9.85 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.