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Plan Details

Network Health Medicare Go (PPO)

Ideal for those who prefer no monthly premium and low copayments.

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Premium

$0 per month

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  • $0 medical deductible
  • $0 copayment for 90-day mail order Tier 1 drugs
  • $0 copayment for in-network primary care provider visits
  • $10 copayment for an annual eye exam
  • $90 emergency room visit
  • 100% coverage for in-network preventive care
  • Prescription drug coverage
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Hearing aid discount benefit
  • Freedom to see in- and out-of-network providers

Southeast Medicare Advantage PPO Plan Benefits

Network Health Medicare Go (PPO)

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

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

(Does not include prescription drugs)

In-network: $4,900
Out-of-network: $5,900 combined in- and out-of-network
Inpatient Hospital1

Per admission.

In-network: $335 per day, Days 1-5 $0 Days 6 and beyond
Out-of-network: $550 per day, Days 1-6 $0 Days 7 and beyond
Outpatient Surgery Services
In-network: $385
Out-of-network: $450
Primary Care Provider Visit
In-network: $0
Out-of-network: $30
Specialist Visit
In-network: $35
Out-of-network: $75
Preventive Care
In-network: $0
Out-of-network: $15
Emergency Room Visit

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

In- and Out-of-network: $90
Urgent Care
In- and Out-of-Network: $45

Diagnostic Lab Tests

In-network: $0-$20
Out-of-network: $30
X-rays
In-network: $35
Out-of-network: $45
Diagnostic Tests

Such as ultrasound, EKG, stress test

In-network: $40
Out-of-network: $50
Radiation Therapy1

Per service

In-network: 20% of the cost
Out-of-network: 25% of the cost
Diagnostic Radiology Services1

Such as MRIs, CT scans

In-network: $200
Out-of-network: $250

Outpatient Ambulatory Surgical Center Services
Such as diagnostic colonoscopies

In-network: $385
Out-of-network: $450

Preventive Dental Exam2
One exam and cleaning per year, X-rays are not included

In-network: See Pick Your Perks Reimbursement Program
Out-of-network: See Pick Your Perks Reimbursement Program
Medicare-Covered Dental Services
In-network: $35, Out-of-network: $75
Comprehensive Dental Benefit2
$38 monthly premium Annual Maximum: $1,000
Routine Eye Exam2

One exam per year

In-network: $10
Out-of-network: $40 reimbursement
Diagnostic Eye Exam
In-network: $35, Out-of-network: $75
Inpatient Mental Health1

Per admission

In- and Out-of-network: $395 per day, Days 1-4 $0 Days 5 and beyond
Outpatient Mental Health

Individual or group therapy

In-network: $40
Out-of-network: $50
Skilled Nursing Facility1

Per admission

In- and Out-of-network: $0 per day, Days 1-20 $184 per day, Days 21-57 $0 Days 58-100
Physical, Occupational, Speech Outpatient Therapy

Includes comprehensive outpatient rehabilitation facility

In-network: $40
Out-of-network: $75
Ambulance - Air and Ground Services

In- and Out-of-network: $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
In-network: 20% of the cost
Out-of-network: 50% of the cost
Medicare Part D Drugs

See prescription drug chart for tier information

In-network: Covered
Out-of-network: Covered
Chiropractic Services

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

In-network: $20
Out-of-network: $40
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.

In-network: $0 for up to a 90-day supply
Out-of-network: $0 for up to a 90-day supply
Dialysis

Per treatment

In-network: 20% of the cost
Out-of-network:25% of the cost
Diabetic Shoe Inserts

Copayment per pair

In-network: $10
Out-of-network: $30
Durable Medical Equipment

Such as insulin pumps, CPAP machines, prosthetic devices

In-network: 20% of the cost
Out-of-network: 25% of the cost
Medicare-Covered Home Health Care Visits1
In-network: $0
Out-of-network: $15
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

See Pick Your Perks Reimbursement Program, discounts also included
SilverSneakers® Fitness2
Included
Over-the-Counter Coverage2
In- and Out-of-network: See Pick Your Perks Reimbursement Program
Pick Your Perks Reimbursement Program2

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

$775 maximum reimbursement per year

Network Health Medicare Go (PPO) Drug Costs

When your coverage starts, you pay a deductible for tiers 4 and 5 only; and copayments until total drug costs (what you and Network Health pay) reach $4,130.
Drug Deductible
$0 for Tiers 1, 2 and 3, $275 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.

Copyright 2021 Network Health Plan, Network Health Insurance Corporation and Network Health Administrative Services, LLC. All rights reserved. HMO and POS plans underwritten by Network Health Plan. Self-insured plans administered by Network Health Administrative Services, LLC. Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. NetworkCares is a PPO D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. Y0108_1850-02-0920_2021 Accepted 09292020 Last Updated Mar 15, 2021 9:49 AM

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