Northeast Medicare Advantage PPO Plan Benefits
Network Health Plus (PPO)
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
Annual Medicare Wellness Visit
$0
Medicare-Covered Vaccines
Flu, pneumonia, COVID-19
$0
Part B Vaccines
Hepatitis B, all other Part B vaccines
$0
Inpatient Hospital Services1
Per admission
$175 per day, days 1-5
$0 days 6 and beyond
Outpatient Hospital Services
$350
Diagnostic Tests
Such as ultrasound, EKG, stress test
$25
Diagnostic Radiology Services– Advanced Imaging
$100
Urgent Care Visit
Free-standing facility
$40
Emergency Room Visit
Copayment is waived if admitted to a U.S. hospital within 24 hours
$110
Air and Ground Ambulance Services
$250
Durable Medical Equipment
Such as insulin pumps1, CPAP machines, prosthetic devices1
20% of the cost
Home Infusion Supplies
$0
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 services2
$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
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.
$110 per incident
$100,000
Maximum benefit
Pick Your Perks2
Not available
Dental Services2, 3
Preventive: 1 cleaning and exam per year for $30
Out-of-Network: $100 reimbursement
Medicare-Covered Dental Services
Does not include services in connection with care, treatment, filling, removal or replacement of teeth
$25
Optional Comprehensive Dental Coverage2
$42 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 Coverage2
Two orders per quarter
$225 per quarter
No rollover on quarterly allowance
Fitness with SilverSneakers®2
Included
Routine Hearing Exam2
In-Network: $0
Out-of-Network: $40
Diagnostic Hearing Exam
$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
Once you reach your maximum out-of-pocket, you will pay $0 per day
$20 per day, days 1-20
$203 per day, days 21-40
$0 days 41-100
Outpatient Physical1, Occupational1, Speech Therapy
$40
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 cost
Radiation Therapy1
Per service
$60
Acupuncture
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 Accu-Chek™ test strips
Continuous glucose monitoring supplies 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
20% of the cost, up to $35
Diabetic Shoe Inserts
Copayment per pair
$10
Non-Emergency Transportation
24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)
Covered
*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
1 Service may require prior authorization.