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.
_Premium
$0
Enroll Now- $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)
(Does not include Part D prescription drugs)
Out-of-Network: $6,500
Out-of-Network: $30
Out-of-Network: $75
Out-of-Network: $15
Out-of-Network: $15
Flu, pneumonia, COVID-19
Hepatitis B, all other Part B vaccines
Out-of-Network: $15
Per admission
$0 Days 7 and beyond
Out-of-Network: $550 per day, Days 1-6
$0 Days 7 and beyond
$225 at an ambulatory surgical center
Out-of-Network: $450
$450 at an ambulatory surgical center
Out-of-Network: $30
Such as ultrasound, EKG, stress test
Out-of-Network: $50
Out-of-Network: $45
Out-of-Network: $250
Copayment is waived if admitted to a U.S. hospital within 24 hours
Such as insulin pumps1, CPAP machines, prosthetic devices1
Out-of-Network: 25% of the cost
For medical (including dermatology) and mental health
Out-of-Network: 50% of the cost
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
Out-of-Network: $75
Annual Maximum: $1,000
Out-of-Network: $40 reimbursement
To diagnose and treat diseases and conditions of the eye
Out-of-Network: $75
One pair of eyeglasses or contact lenses after each cataract surgery
Out-of-Network: $75
Out-of-Network: $40
Out-of-Network: $75
Maximum of two hearing aids per year
Hearing aid evaluation and fitting included
Individual or group therapy
Out-of-Network: $50
Per admission
$0 Days 5 and beyond
Out-of-Network: $50
Outpatient individual or group therapy
Out-of-Network: $50
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
Out-of-Network: $75
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
Out-of-Network: $40
For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year
Out-of-Network: $75
Out-of-Network: $15
Out-of-Network: 50% of the cost
Out-of-Network: 25% of the cost
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
Out-of-Network: $15
In addition to 24 trips, up to $1,500 reimbursed through Pick Your Perks for rides to medical appointments and pharmacies
Out-of-Network: 25% of the cost
Network Health Medicare Go (PPO) Drug 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
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
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.