Medicare Plans

Network Health Medicare Explore (HMO) 

$35 per month

Medical and pharmacy coverage with a low monthly premium and low copayments

  • $35 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

Services with a 1 may require prior authorization.

Network Health Medicare
Explore HMO Benefits
Network Health Medicare Explore (HMO)
Premium

$35 per month (Includes pharmacy)

Deductible

This plan does not have a medical deductible.

Maximum Out-of-Pocket

$4,900 per year

Inpatient Hospital Coverage1

Days 1-6 $295/day copayment
Days 7 and beyond $0 copayment

Outpatient Surgery Services1

$295 copayment

Primary Care Provider

$0 copayment

Specialist

$30 copayment

Preventive Care

$0 copayment

Emergency Room

$90 copayment

Urgent Care

$45 copayment

Low Cost Labs

$0 copayment

Lab and Clinical Diagnostic Tests

$15 copayment

Outpatient X-rays

$25 copayment

Ultrasound, EKGs, EEGs,
Stress Test

$35 copayment

Radiation Therapy

$60 copayment

Diagnostic Radiology Services
(Such as MRIs, CT Scans)

$125 copayment

Medicare Covered Hearing Exams

$10 copayment

Medicare Covered Dental1

$50 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

Supplemental Dental

One exam and cleaning per year with Delta Dental Medicare Advantage Provider.
$30 copayment

Medicare Covered
Eye Exam

$50 copayment

Supplemental Vision

$10 copayment, maximum $30 reimbursement out-of-network

Inpatient Mental Health Care

Days 1-5 $295 copayment/day
Days 6-190 $0 copayment including “lifetime reserve days”

Outpatient Mental Health Care

Individual or group therapy $30 copayment

Skilled Nursing Facility1

Days 1-20 $0 copayment/day
Days 21-49 $172 copayment/day
Days 50-100 $0 copayment

Physical Therapy

$30 copayment

Ambulance

$225 copayment

Transportation

Not covered

Medicare Part B Drugs
and Chemotherapy

20% of the cost

Medicare Part D Drugs

Covered

Chiropractic Care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
$20 copayment

Diabetes Monitoring Supplies
and Test Strips1

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a 90-day supply

Diabetes Self-Monitoring Training1

$0 copayment

Therapeutic Shoes/Inserts1

$10 copayment

Durable Medical Equipment

20% of the cost

Prosthetic Devices

20% of the cost

Related Medical Supplies1

20% of the cost

Home Health Care1

$0 copayment

 

This information is not a complete description of benefits. Call 800-378-5237 (TTY 800-947-3529) for more information.

 

 Network Health Medicare Explore (HMO) Drug Plan Costs

When your coverage starts, you pay a deductible for tiers 3, 4 and 5 only; and copayments until total drug costs (what you and Network Health pay) reach $3,820.

Drug Deductible

$260 For tiers 3, 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      $84 for Tier 4
28% for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1     $47 for Tier 3
$14 for Tier 2   $91 for Tier 4
28% for Tier 5

90-Day Supply Preferred Pharmacy
$5 for Tier 1      $105 for Tier 3
$20 for Tier 2    $210 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     $228 for Tier 4
Tier 5 is not available

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

90-Day Mail Order Pharmacy
$0 for Tier 1     $105 for Tier 3
$20 for Tier 2     $210 for Tier 4
Tier 5 is not available

 Coverage Gap

You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

 Catastrophic
 Coverage

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.


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.