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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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  • $1,200 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 $3,900 in-network
  • $0 medical deductible
  • $0 pharmacy deductible on Tier 1
  • $0 copayment for 31- to 100-day supply for Tier 1 and 31- to 90-day supply for Tier 2 drugs after deductible at preferred mail order
  • 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
$0
Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

In-Network: $3,900
Out-of-Network: $6,200
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 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: $800 per day, days 1-7
$0 days 8 and beyond
Outpatient Hospital Services1
In-Network: $0-$275
$0-$225 at an ambulatory surgical center

Out-of-Network: $0-$550
$0-$450 at an ambulatory surgical center
Labs
In-Network: $0-$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

$125
Air and Ground Ambulance Services
$275
Durable Medical Equipment

Such as insulin pumps1, CPAP machines1, prosthetic devices1

In-Network: 20% of the cost
Out-of-Network: 25% of the cost
Home Infusion Therapy

Medical supplies

In-Network: 0% coinsurance
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 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 cost
Out-of-Network: 50% of the cost
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

$125 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

$1,200
Dental Services2
Up to $1,200 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
$45 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 $1,200 reimbursement through Pick Your Perks
Over-the-Counter Coverage2
Up to $1,200 reimbursed through Pick Your Perks
Fitness with One Pass™2
Included
Routine Hearing Exam2
In-Network: $0
Out-of-Network: $40
Diagnostic Hearing Exam
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
$214 per day, days 21-45
$0 days 46-100
Outpatient Physical1, Occupational1, Speech Therapy
In-Network: $50
Out-of-Network: $100
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: $50
Out-of-Network: $100
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
Per service
In-Network: 20% of the cost
Out-of-Network: 40% of the cost
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

One Touch™ 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 Insulin

One-month supply

In-Network: 20% of the cost, up to $35
Out-of-Network: 50% of the cost
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 $1,200 reimbursed through Pick Your Perks for rides to medical appointments and pharmacies
Dialysis

Per treatment

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/extra-benefits for more information.
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.

Network Health Go (PPO) Drug Costs

Annual Drug Deductible
$320 Applies to Tiers 2-5
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
24% for Tier 3
37% for Tier 4
29% of the cost for Tier 5

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

$5 for Tier 1
$20 for Tier 2
24% for Tier 3
37% for Tier 4
Tier 5 is not available

31 to 100-Day 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 after deductible

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 after deductible
24% for Tier 3
37% for Tier 4
Tier 5 is not available

30-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy
$7 for Tier 1
$15 for Tier 2
25% for Tier 3
37% for Tier 4
29% of the cost 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

$17 for Tier 1
$37 for Tier 2
25% for Tier 3
37% for Tier 4
Tier 5 is not available

Catastrophic Coverage
You enter catastrophic coverage when your total out-of-pocket costs reach $2,000. You pay $0.
Part D Insulin
One-month supply
$35
Part D Vaccines
Shingrix, Tdap, all other adult ACIP recommended vaccines
$0

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.

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