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Plan Details

Network Health 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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  • $750 Pick Your Perks flexible benefits program available, covering dental, vision hardware, over-the-counter items, acupuncture, massage therapy and more
  • Annual maximum out-of-pocket of $5,000 in-network
  • $0 pharmacy deductible on Tier 1
  • $0 copayment for up to a 100-day supply for Tier 1 at preferred retail or preferred mail order, $0 copayment for 31- to 90-day supply for Tier 2 drugs at preferred mail order, after deductible
  • 100% coverage for in-network preventive care
  • Travel coverage
  • Prescription drug coverage
  • One Pass™ fitness benefit
  • $0 copayment for in-network personal doctor (primary care provider) visits
  • $50 copayment for in-network specialist visit
  • $10 copayment for an annual routine vision exam
  • Freedom to see in- and out-of-network providers (costs may be lower when seeing in-network providers)

Southeast Medicare Advantage PPO Plan Benefits

Network Health Go (PPO)

Monthly Premium
$0
Annual Medical Deductible
$270
Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

In-Network: $5,000
Out-of-Network: $7,900
Primary Care Provider Visit
In-Network: $0
Out-of-Network: $30
Deductible applies out-of-network
Specialist Visit
In-Network: $50
Out-of-Network: $100
Deductible applies out-of-network
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: $350 per day, days 1-6
$0 days 7 and beyond

Out-of-Network: $800 per day, days 1-7
$0 days 8 and beyond
Deductible applies
Outpatient Hospital Services1
In-Network: $300
Out-of-Network: $600
Deductible applies
Ambulatory Surgical Center
In-Network: $250
Out-of-Network: $500
Deductible applies out-of-network
Labs
In-Network: $0 or $20
Out-of-Network: $40
Deductible applies out-of-network
Diagnostic Tests1

Such as ultrasound, EKG, stress test

In-Network: $35
Out-of-Network: $70
Deductible applies
Diagnostic Mammograms
In-Network: $0
Out-of-Network: $70
Deductible applies out-of-network
X-rays
In-Network: $35
Out-of-Network: $70
Deductible applies
Diagnostic Radiology Services– Advanced Imaging1
In-Network: $300
Out-of-Network: $600
Deductible applies
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
$300
Deductible applies out-of-network
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
Deductible applies
Durable Medical Equipment for Home Infusion

Medical supplies

In-Network: 0% coinsurance
Out-of-Network: 25% of the allowed amount
Deductible applies out-of-network
Physician Telehealth Services
Virtual primary care and urgent care services cost the same as an in-person visit
Deductible applies out-of-network
Virtual Visit with MDLIVE®2

For medical services

In-network: $0
Deductible applies out-of-network
Medicare Part B Drugs1
In-Network: 20% of the allowed amount
Out-of-Network: 50% of the allowed amount
Deductible applies
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.
International Emergency Coverage

View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details

$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

$750
Dental Services2
Up to $750 reimbursement 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
Deductible applies out-of-network
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: $50
Out-of-Network: $100
Deductible applies out-of-network
Post-Cataract Eyewear2

One pair of eyeglasses or contact lenses after each cataract surgery

In-Network: $0
Out-of-Network: $100
Deductible applies out-of-network
Additional Eyewear2
Up to $750 reimbursement through Pick Your Perks
Over-the-Counter Catalog2
Up to $750 reimbursement through Pick Your Perks
Fitness with One Pass™2
In-Network: $0
Routine Hearing Exam2
In-Network: $0
Diagnostic Hearing Exam

Exam to diagnose and treat hearing issues

In-Network: $50
Out-of-Network: $100
Deductible applies out-of-network
Fitting/Evaluation for Hearing Aids
In-Network: $0
Hearing Aids2

Maximum of two hearing aids per year
Hearing aid evaluation with TruHearing and fitting included in-network

In-Network: $495-$1,695 per device
Hearing aids must be purchased through TruHearing
Outpatient Mental Health

Individual or group therapy

In-Network: $50
Out-of-Network: $100
Deductible applies out-of-network
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
Deductible applies
Opioid Treatment Services
In-Network: $50
Out-of-Network: $100
Deductible applies out-of-network
Substance Abuse Services

Outpatient individual or group therapy

In-Network: $50
Out-of-Network: $100
Deductible applies out-of-network
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
$221 per day, days 21-45
$0 days 46-100
Deductible applies
Outpatient Physical1, Occupational1, Speech Therapy
In-Network: $50
Out-of-Network: $100
Deductible applies
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
Deductible applies out-of-network
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
Deductible applies out-of-network
Medicare-Covered Home Health Care Visits1
In-Network: $0
Out-of-Network: $15
Deductible applies
Chemotherapy1
In-Network: 20% of the allowed amount
Out-of-Network: 50% of the allowed amount
Deductible applies
Radiation Therapy1
Per service
In-Network: 20% of the allowed amount
Out-of-Network: 40% of the allowed amount
Deductible applies
Diabetes Monitoring Supplies and Test Strips

Accu-Chek™ and FreeStyle™ test strips
FreeStyle Libre® and Dexcom® continuous glucose monitoring devices and supplies1 obtained through your pharmacy. Must have diabetic diagnosis. All other brands not covered.

Deductible applies out-of-network.

$0 for up to a 90-day supply
Deductible applies out-of-network
Part B Insulin1

One-month supply

In-Network: No more than $35
Out-of-Network: 50% of the allowed amount
Diabetic Shoe Inserts

Copayment per pair

In-Network: $10
Out-of-Network: $30
Deductible applies
Dialysis

Per treatment

In-Network: 20% of the allowed amount
Out-of-Network: 25% of the allowed amount
Deductible applies
*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/extra-benefits for more information.

Network Health Go (PPO) Drug Costs

Annual Drug Deductible
$340 Applies to Tiers 2-5
INITIAL COVERAGE Cost share applies after deductible is met. Amount shown is the maximum you will pay. You may pay less.

30-Day Supply
Preferred Pharmacy or Preferred Mail Order Pharmacy
$0 for Tier 1
$8 for Tier 2
22% for Tier 3
31% for Tier 4
29% for Tier 5

3-Month Supply
Preferred Pharmacy
100-day for Tier 1
90-day for Tier 2-4

$0 for Tier 1
$20 for Tier 2
22% for Tier 3
31% for Tier 4
Tier 5 is not available

3-Month Supply
Preferred Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2-4

$0 for Tier 1
$0 for Tier 2
22% for Tier 3
31% for Tier 4
Tier 5 is not available

30-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy
$8 for Tier 1
$17 for Tier 2
25% for Tier 3
31% for Tier 4
29% for Tier 5

3-Month Supply
Standard Pharmacy or Standard Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2-4

$20 for Tier 1
$42 for Tier 2
25% for Tier 3
31% for Tier 4
Tier 5 is not available

Catastrophic Coverage
You enter catastrophic coverage when your total out-of-pocket costs reach $2,400. You pay $0.
Part D Insulin1
One-month supply
No more than $35
Part D Vaccines
Shingrix, RSV, all other adult vaccines recommended by the Advisory Committee on Immunization Practices
$0

This information is not a complete description of benefits. Call 800-378-5234 (TTY 711) 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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