Southeast Medicare Advantage PPO Plan Benefits
Network Health Go (PPO)
 
Annual Medical Deductible
$0
 
Annual Maximum Out-of-Pocket
(Does not include Part D prescription drugs)
 
In-Network: $4,500
Out-of-Network: $7,400
 
Primary Care Provider Visit
In-Network: $0
Out-of-Network: $30
 
Specialist Visit
In-Network: $50
Out-of-Network: $100
 
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 B1, 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: $800 per day, days 1-7
$0 days 8 and beyond
 
Outpatient Hospital Services1
In-Network: $275
$225 at an ambulatory surgical center
Out-of-Network: $550
$450 at an ambulatory surgical center
 
Labs
In-Network: $0 or $20
Out-of-Network: $40
 
Diagnostic Tests1
Such as ultrasound, EKG, stress test
 
In-Network: $35
Out-of-Network: $70
 
X-rays
In-Network: $35
Out-of-Network: $70
 
Diagnostic Radiology Services– Advanced Imaging1
In-Network: $275
Out-of-Network: $550
 
Urgent Care Visit
Free-standing facility
$50
 
Emergency Room Visit
Copayment is waived if admitted to a U.S. hospital within 24 hours
 
$130
 
Air and Ground Ambulance Services
$275
 
Durable Medical Equipment
Such as insulin pumps1, CPAP machines, prosthetic devices1
 
In-Network: 20% of the allowed amount
Out-of-Network: 25% of the allowed amount
 
Durable Medical Equipment for Home Infusion
Medical supplies
 
In-Network: 0% coinsurance
Out-of-Network: 25% of the allowed amount
 
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 services
 
In-network: $0
 
Medicare Part B Drugs1
Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.
 
In-Network: 20% of the allowed amount
Out-of-Network: 50% of the allowed amount
 
Medicare Part D Drugs¹
Covered
 
Travel within the United States
Receive in-network coverage when you see a provider outside Wisconsin and within the United States territories. You can see any provider who accepts Medicare beneficiaries.
 
$130 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
 
$1,155
 
Dental Services2
Up to $1,155 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: $50
Out-of-Network: $100
 
Optional Comprehensive Dental Coverage2
$49 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: $50
Out-of-Network: $100
 
Post-Cataract Eyewear2
One pair of eyeglasses or contact lenses after each cataract surgery
 
In-Network: $0
Out-of-Network: $100
 
Additional Eyewear2
Up to $1,155 reimbursement through Pick Your Perks
 
Over-the-Counter Catalog2
Up to $1,155 reimbursed through Pick Your Perks
 
Fitness with One Pass™2
Included
 
Routine Hearing Exam2
In-Network: $0
Out-of-Network: $40
 
Diagnostic Hearing Exam
Exam to diagnose and treat hearing issues
 
In-Network: $50
Out-of-Network: $100
 
Hearing Aids2
Maximum of two hearing aids per year
Hearing aid evaluation with TruHearing and fitting included
 
$495-$1,695 per device
Hearing aids must be purchased through TruHearing
No coverage out-of-network
 
Outpatient Mental Health
Individual or group therapy
 
In-Network: $50
Out-of-Network: $100
 
Inpatient Mental Health1
Per admission
 
In-Network: $395 per day, days 1-4
$0 days 5 and beyond
Out-of-Network: $800 per day, days 1-7
$0 per day, days 8 and beyond
 
Opioid Treatment Services
In-Network: $50
Out-of-Network: $100
 
Substance Abuse Services
Outpatient individual or group therapy
 
In-Network: $50
Out-of-Network: $100
 
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
$218 per day, days 21-45
$0 days 46-100
 
Outpatient Physical1, Occupational1, Speech Therapy
In-Network: $50
Out-of-Network: $100
 
Medicare-Covered Chiropractic Services
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
 
In-Network: $15
Out-of-Network: $30
 
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: $50
Out-of-Network: $100
 
Medicare-Covered Home Health Care Visits1
In-Network: $0
Out-of-Network: $15
 
Chemotherapy1
In-Network: 20% of the allowed amount
Out-of-Network: 50% of the allowed amount
 
Radiation Therapy1
Per service
In-Network: 20% of the allowed amount
Out-of-Network: 40% of the allowed amount
 
Acupuncture3
Up to 12 visits per year are covered for members who are undergoing chemotherapy and have severe nausea and/or vomiting.
 
$0
 
Diabetes Monitoring Supplies and Test Strips
Accu-Chek™ and FreeStyle™ test strips
Continuous glucose monitoring supplies1 limited to eligible FreeStyle Libre® and Dexcom® obtained through your pharmacy. All other brands are not covered.
 
$0 for up to a 90-day supply
 
Part B Insulin1
One-month supply
 
In-Network: 20% of the allowed amount, up to $35
Out-of-Network: 50% of the allowed amount
 
Diabetic Shoe Inserts
Copayment per pair
 
In-Network: $10
Out-of-Network: $30
 
Non-Emergency Transportation3
24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)
 
In addition to 24 trips, up to $1,155 reimbursed through Pick Your Perks for rides to medical appointments and pharmacies
 
In-Network: 20% of the allowed amount
Out-of-Network: 25% of the allowed amount
 
*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.
 
3This is a Special Supplemental Benefit for the Chronically Ill (SSBCI) benefit. In addition to an eligible chronic condition, members must also meet additional eligibility requirements to receive the SSBCI benefit.