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Plan Details

Network Health Medicare Go (PPO)

Ideal for those who prefer to pay for services with low copayments and not have a monthly premium.

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Premium

$0

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  • $1,500 Pick Your Perks flexible benefits program available, covering dental, vision hardware, over-the-counter items, acupuncture, massage therapy and more
  • Prescription drug coverage
  • Annual maximum out-of-pocket of $4,500 in-network
  • SilverSneakers® Fitness benefit
  • $0 medical deductible
  • $0 copayment for personal doctor (primary care provider) visits
  • $0 pharmacy deductible on Tiers 1 and 2
  • $35 copayment for specialist visit
  • $0 copayment for mail order Tier 1 and 2 drugs at a preferred mail order pharmacy
  • $10 copayment for an annual routine vision exam
  • 100% coverage for preventive care
  • Freedom to see in- and out-of-network providers
  • Travel coverage

Southeast Medicare Advantage PPO Plan Benefits

Network Health Medicare Go (PPO)

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

(Does not include Part D prescription drugs)

In-Network: $4,500
Out-of-Network: $6,500
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
Annual Medicare Wellness Visit
In-Network: $0
Out-of-Network: $15
Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

$0
Part B Vaccines

Hepatitis B, all other Part B vaccines

In-Network: $0
Out-of-Network: $15
Inpatient Hospital Services1

Per admission

In-Network: $295 per day, Days 1-6
$0 Days 7 and beyond

Out-of-Network: $550 per day, Days 1-6
$0 Days 7 and beyond
Outpatient Hospital Services
In-Network: $275
$225 at an ambulatory surgical center

Out-of-Network: $450
$450 at an ambulatory surgical center
Labs
In-Network: $0-$20
Out-of-Network: $30
Diagnostic Tests

Such as ultrasound, EKG, stress test

In-Network: $20
Out-of-Network: $50
X-rays
In-Network: $35
Out-of-Network: $45
Diagnostic Radiology Services– Advanced Imaging
In-Network: $200
Out-of-Network: $250
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

In-Network: 20% of the cost
Out-of-Network: 25% 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
In-Network: 20% of the cost
Out-of-Network: 50% 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

$1,500
Preventive Dental Services2
Up to $1,500 reimbursed through Pick Your Perks
Medicare-Covered Dental Services

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

In-Network: $35
Out-of-Network: $75
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

In-Network: $35
Out-of-Network: $75
Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

In-Network: $0
Out-of-Network: $75
Over-the-Counter Coverage2
Up to $1,500 reimbursed through Pick Your Perks
Fitness with SilverSneakers®2
Included
Routine Hearing Exam2
In-Network: $0
Out-of-Network: $40
Diagnostic Hearing Exam
In-Network: $35
Out-of-Network: $75
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

In-Network: $40
Out-of-Network: $50
Inpatient Mental Health1

Per admission

$395 per day, Days 1-4
$0 Days 5 and beyond
Opioid Treatment Services
In-Network: $40
Out-of-Network: $50
Substance Abuse Services

Outpatient individual or group therapy

In-Network: $40
Out-of-Network: $50
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
In-Network: $40
Out-of-Network: $75
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
Medicare-Covered Acupuncture

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

In-Network: $35
Out-of-Network: $75
Medicare-Covered Home Health Care Visits1
In-Network: $0
Out-of-Network: $15
Chemotherapy1
In-Network: 20% of the cost
Out-of-Network: 50% of the cost
Radiation Therapy1
In-Network: 20% of the cost
Out-of-Network: 25% 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

In-Network: $10
Out-of-Network: $15
Non-Emergency Transportation

In addition to 24 trips, up to $1,500 reimbursed through Pick Your Perks for rides to medical appointments and pharmacies

24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)
Dialysis
In-Network: 20% of the cost
Out-of-Network: 25% 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.
2Visit networkhealth.com/medicare/additional-benefits for more information.

Network Health Medicare Go (PPO) Drug Costs

Annual Drug Deductible
$195 Applies to Tiers 3-5
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
29% 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
29% 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.

Copyright 2022 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_1850-03-0921_2022_F Last Updated Feb 28, 2022 2:38 PM

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