Plan Details
Network Health Medicare Explore (HMO)
Ideal for those who prefer to visit in-network doctors and have an affordable monthly premium.
_Premium
$11 per month (includes pharmacy)
Enroll Now- $11 monthly premium
- $0 medical deductible
- $0 copayment for 90-day mail order Tier 1 drugs
- $0 copayment for primary care provider visits
- $10 copayment for an annual eye exam
- $90 emergency room visit
- 100% coverage for preventive care
- Prescription drug coverage
- Snowbird travel coverage
- SilverSneakers® Fitness benefit
- Annual dental exam and cleaning
- Hearing aid discount benefit
Southeast Medicare Advantage PPO Plan Benefits
Network Health Medicare Explore (HMO)
1Service may require prior authorization.
2Visitnetworkhealth.com/medicare/additional-benefits for more information.
(Does not include prescription drugs)
Per admission
Copayment is waived if admitted to a U.S. hospital within 24 hours
Diagnostic Lab Tests
Such as ultrasound, EKG, stress test
Per service
Such as MRIs, CT scans
Such as diagnostic colonoscopies
One exam and cleaning per year, X-rays are not included
Comprehensive Dental Benefit2
Annual Maximum: $1,000
One exam per year
To diagnose and treat diseases and conditions of the eye
Per admission
Outpatient Mental Health
Individual or group therapy
Per admission
Includes comprehensive outpatient rehabilitation facility
Ambulance - Air and Ground Services
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
See prescription drug chart for tier information
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
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.
Dialysis
Per treatment
20% of the cost
Copayment per pair
Durable Medical Equipment
Such as insulin pumps, CPAP machines, prosthetic devices
$0
Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®2
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.
$795-$2,370 per device.
(A savings of up to $1,050 per hearing aid)
Additional Eyewear2
Discounts offered at EyeMed providers
Reimbursement for Medicare-approved supplemental benefits including dental, vision, meals, non-emergency transportation, over-the-counter items, acupuncture, massage therapy expenses and nutritional/dietary benefits
Network Health Medicare Explore (HMO) Drug Plan Costs
$260 for Tiers 4 and 5 only
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
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.