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Plan Details
Network Health Medicare Explore (HMO)
Ideal for those who prefer to visit in-network doctors and have low copayments.
_Premium
$11
Enroll Now- Medical and pharmacy coverage with $11 monthly premium and low copayments
- Annual maximum out-of-pocket of $4,100
- SilverSneakers® Fitness benefit
- $0 medical deductible
- $0 copayment for personal doctor (primary care provider) visits
- $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
- $0 copayment for annual routine hearing exam
- $10 copayment for an annual routine vision exam
- One dental cleaning and exam per year for $30
- $25 quarterly over-the-counter benefit
- 100% coverage for preventive care
Southeast Medicare Advantage PPO Plan Benefits
Network Health Medicare Explore (HMO)
(Does not include Part D prescription drugs)
Flu, pneumonia, COVID-19
Hepatitis B, all other Part B vaccines
Per admission
$0 Days 6 and beyond
Such as ultrasound, EKG, stress test
Copayment is waived if admitted to a U.S. hospital within 24 hours
Such as insulin pumps1, CPAP machines, prosthetic devices1
For medical (including dermatology) and mental health
View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details
$100,000
Maximum benefit
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
Does not include services in connection with care, treatment, filling, removal or replacement of teeth
Annual Maximum: $1,000
To diagnose and treat diseases and conditions of the eye
One pair of eyeglasses or contact lenses after each cataract surgery
No rollover on quarterly allowance
Maximum of two hearing aids per year
Hearing aid evaluation and fitting included
Individual or group therapy
Per admission
$0 Days 6 and beyond
Outpatient individual or group therapy
Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day
$188 per day, Days 21-45
$0 Days 46-100
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year
Up to 12 visits per year are covered for members who are undergoing chemotherapy and experiencing nausea
One Touch™ and Accu-Chek™ test strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered.
Copayment per pair
24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)
Network Health Medicare Explore (HMO) Drug Plan Costs
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
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.
