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Plan Details

Network Health PlusRx (PPO)

Ideal for those who prefer to pay a monthly premium and reduced copayments with prescription drug coverage.

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Premium

$73

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  • Same costs for in- and out-of-network providers (excluding annual routine vision, dental and hearing exams)
  • Annual maximum out-of-pocket of $3,400
  • $0 medical deductible
  • $750 combined in- and out-of-network annual maximum dental benefit
  • $0 pharmacy deductible on Tier 1
  • $0 copayment for an annual in-network routine hearing exam
  • Travel coverage
  • Medical and pharmacy coverage with a $73 monthly premium
  • One Pass™ fitness benefit
  • $15 copayment for personal doctor (primary care provider) visits
  • $0 copayment for up to a 100-day supply for Tier 1 drugs at preferred retail and preferred mail order. $0 copayment for a 31- to 90-day supply for Tier 2 drugs at preferred mail order, after deductible.
  • $140 quarterly over-the-counter benefit
  • 100% coverage for preventive care

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
$0
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*
$0
Annual Medicare Wellness Visit
$0
Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

$0
Part B Vaccines

Hepatitis B1, all other Part B vaccines

$0
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

$0
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

$0
Over-the-Counter Catalog2
Two orders per quarter
$140 per quarter
No rollover on quarterly allowance
Fitness with OnePass2
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
$0
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.

$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

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
$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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