Plan Details

Network Health Medicare Go (PPO)

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

Premium

$0 per month

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$0 medical deductible
$0 copayment for 90-day mail order Tier 1 drugs
$10 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
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)

Services with a ¹ may require prior authorization.

Monthly Premium

Annual Medical Deductible

Annual Maximum Out-of-Pocket

Combined in- and out-of-network

$5,900

Inpatient Hospital Coverage¹

Per admission.

In-network: $395 per day, Days 1-4 $0 Days 5 and beyond
Out-of-network: $495 per day, Days 1-5 $0 Days 6 and beyond

Outpatient Surgery Services

Including Ambulatory Surgical Center Services such as colonoscopies.

In-network: $385
Out-of-network: $415

Primary Care Provider

In-network: $10
Out-of-network: $20

Specialist

In-network: $45
Out-of-network: $75

Preventive Care

In-network: $0
Out-of-network: $15

Emergency Room

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

Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization¹

In-network: $0-$20
Out-of-network: $30

X-rays

In-network: $35 copayment
Out-of-network: $45 copayment

Ultrasound, EKGs, EEGs, 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: $125
Out-of-network: $140

Medicare Covered Hearing Exams

Diagnostic

In-network: $15
Out-of-network: $25

Medicare Covered Dental Exam

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

In-network: $50
Out-of-network: $55

Optional Dental Benefit with Delta Dental Medicare Advantage

In-network: $37 monthly premium
Annual Maximum: $1,000

Medicare Covered Eye Exam

In-network: $50
Out-of-network: $55

Inpatient Mental Health¹

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

Outpatient Individual or Group Therapy, Psychiatric, Telehealth

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

Skilled Nursing Facility¹

In- and Out-of-network: $0 Days 1-20 $178 per day, Days 21-57

Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

In-network: $40
Out-of-network: $75

Ambulance

In- and Out-of-network: $275 copayment

Transportation

Not covered

Medicare Part B Drugs and Chemotherapy

In-network: 20% of the cost
Out-of-network: 50% of the cost

Medicare Part D Drugs

In-network: covered
Out-of-network: Not covered

Chiropractic Care

Manipulation of the spine to correct when one or more of the bones in your spine move out of position.

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

Diabetes Monitoring Supplies and Test Strips¹

One Touch™ and Accu-Chek™ 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

Diabetes Self-Monitoring Training¹

In- and Out-of-network: $0 copayment

Diabetic Shoes/Inserts

In- and Out-of-network: $10 copayment

Durable Medical Equipment Such as Insulin Pumps¹ CPAP machines, Prosthetic Devices¹

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

MDLIVE® Virtual Doctor Visits

Hearing Aid Discount
Includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Maximum of two hearing aids per year.

Select hearing aids discounted to
$1,220-$1,985 per device.
Save $775–$1,215 per hearing aid.

Non-Medicare Covered
Eyewear Discounts offered at EyeMed providers.

Discounts included

SilverSneakers^® Fitness

Included

Caregiver Support

Included

Over-the-Counter Coverage

Not included

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 $4,020.

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 $84 for Tier 4
27% for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1 $47 for Tier 3
$14 for Tier 2 $91 for Tier 4
27% 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 $4,020. 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 $6,350. You pay the greater of $3.60 or 5%a of the cost for generic drugs and $8.95 or 5% of the cost for brand name drugs.

This information is not a complete description of benefits. Call 800-378-5237 (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.

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Medicare Plans

Plan Details

Network Health Medicare Go (PPO)

Premium

Southeast Medicare Advantage PPO Plan Benefits

Network Health Medicare Go (PPO)

Network Health Medicare Go (PPO) Drug Costs