Network Health PlusRx (PPO)

Northeast Medicare Advantage PPO Plan Benefits

Network Health PlusRx (PPO)

Monthly Premium

$73

Monthly Part B Premium Giveback²

Must be enrolled in Medicare Parts A and B, pay own premium and live in a service area that offers this benefit

N/A

Annual Medical Deductible

Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

$3,400 Combined in- and out-of-network

Primary Care Provider Visit

$15

Specialist Visit

$40

Preventive Care*

Annual Medicare Wellness Visit

Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

Part B Vaccines

Hepatitis B¹, all other Part B vaccines

Inpatient Hospital Services¹

Per admission

$175 per day, days 1-5
$0 days 6 and beyond

Outpatient Hospital Services¹

$350

Labs

$0 or $5

Diagnostic Tests¹

Such as ultrasound, EKG, stress test

$25

X-rays

$25

Diagnostic Radiology Services– Advanced Imaging¹

$100

Urgent Care Visit
Free-standing facility

$40

Emergency Room Visit

Copayment is waived if admitted to a U.S. hospital within 24 hours

$130

Air and Ground Ambulance Services

$250

Durable Medical Equipment

Such as insulin pumps¹, CPAP machines, prosthetic devices¹

20% of the allowed amount

Durable Medical Equipment for Home Infusion

Medical supplies

0% coinsurance

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

Medicare Part B Drugs¹

Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.

20% of the cost

Medicare Part D Drugs¹

Covered

Travel within the United States

Receive in-network coverage when you venture 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

Not available

Dental Services²

In-Network: 100% coverage for preventive
50% coverage for comprehensive
$750 combined annual maximum

Out-of-Network: Member pays 80% of the allowed amount

Out-of-network dentists do not have a contract with Say Cheese Dental Network, so they have not agreed to a contracted price or payment amount for dental services. Additionally, out-of-network dentists can balance bill you the difference between the charges they bill for their services and Say Cheese Dental Network’s allowed payment amount.

Medicare-Covered Dental Services

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

$25

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

$25

Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

Over-the-Counter Catalog²
Two orders per quarter

$140 per quarter
No rollover on quarterly allowance

Fitness with OnePass^™²

Included

Routine Hearing Exam²

In-Network: $0
Out-of-Network: $40

Diagnostic Hearing Exam

Exam to diagnose and treat hearing issues

$25

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

$35

Inpatient Mental Health¹

Per admission

$150 per day, days 1-10
$0 days 11 and beyond

Opioid Treatment Services

$35

Substance Abuse Services

Outpatient individual or group therapy

$20

Skilled Nursing Facility¹

Per admission

$20 per day, days 1-20
$218 per day, days 21-40
$0 Days 41-100

Outpatient Physical¹, Occupational¹, Speech Therapy

$40

Medicare-Covered Chiropractic Services

Manipulation of the spine to correct misalignment of one or more of the bones of your spine

$20

Medicare-Covered Acupuncture

For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year

$40

Medicare-Covered Home Health Care Visits¹

Chemotherapy¹

20% of the allowed amount

Radiation Therapy¹
Per service

$60

Acupuncture³

Up to 12 visits per year are covered for members who are undergoing chemotherapy and have severe nausea and/or vomiting.

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

20% of the cost, up to $35

Diabetic Shoe Inserts

Copayment per pair

$10

Non-Emergency Transportation³

24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)

Covered

Dialysis

Per treatment

20% 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.

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 PlusRx (PPO) Drug Plan Costs

Annual Drug Deductible

$340
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
$0 for Tier 1
$8 for Tier 2
23% for Tier 3
25% 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

$0 for Tier 1
$20 for Tier 2
23% for Tier 3
25% 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 after deductible
23% for Tier 3
25% 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
25% 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

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

Catastrophic Coverage

You enter catastrophic coverage when your total out-of-pocket costs reach $2,100. You pay $0.

Part D Insulin¹
One-month supply

Lesser of 25% or $35

Part D Vaccines
Shingrix, RSV, all other adult ACIP recommended vaccines

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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