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Medicare Plans

Plan Details

Network PlatinumPlus (PPO)

Ideal for those who prefer a monthly payment and lower copayments.

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Premium

$51 per month

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  • Same costs for in- and out-of-network providers
  • $0 medical deductible
  • $10 copayment for an in-network annual eye exam
  • $15 copayment for primary care provider visits
  • $120 emergency room visit
  • $3,400 maximum out-of-pocket (combined in- and out-of-network)
  • 100% coverage for preventive care
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Hearing aid discount benefit
  • Annual dental exam and cleaning

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPlus (PPO)

1Service may require prior authorization.
2Visitnetworkhealth.com/medicare/additional-benefits for more information.

Monthly Premium
$51
Annual Medical Deductible
$0
Annual Maximum Out-of-Pocket

(Combined In- and Out-of-Network) (Does not include prescription drugs)

$3,400
Inpatient Hospital1

Per admission

$175 per day, Days 1-5 $0 Days 6 and beyond
Outpatient Surgery Services
$350
Primary Care Provider Visit
$15
Specialist Visit
$40
Preventive Care
$0
Emergency Room Visit

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

$120
Urgent Care
$40
Diagnostic Lab Tests
$0-$5
X-rays
$25
Diagnostic Tests

Such as ultrasound, EKG, stress test

$25
Radiation Therapy1

Per service

$60
Diagnostic Radiology Services1

Such as MRIs, CT scans

$100
Outpatient Ambulatory Surgical Center Services

Such as diagnostic colonoscopies

$350
Preventive Dental Exam2

One exam and cleaning per year, X-rays are not included

$30 in-network

$100 reimbursement out-of-network

Medicare-Covered Dental Services
$25
Comprehensive Dental Benefit2
$38 monthly premium Annual Maximum: $1,000
Routine Eye Exam2

One exam per year

$10 in-network, $40 reimbursement out-of-network 

Diagnostic Eye Exam

$25

Inpatient Mental Health1

Per admission

$150 per day, Days 1-10 $0 Days 11 and beyond
Outpatient Mental Health

Individual or group therapy

$35
Skilled Nursing Facility1

Per admission

$20 per day, Days 1-20 $184 per day, Days 21-54, $0 Days 55-100
Physical, Occupational, Speech Outpatient Therapy

Includes comprehensive outpatient rehabilitation facility

$40

Ambulance - Air and Ground Services

$250
Transportation - Non-Emergency

Includes 24 one-way trips for all members diagnosed with end stage renal disease (ERSD), to get to and from dialysis for treatment

Covered
Medicare Part B Drugs and Chemotherapy1
20% of the cost
Medicare Part D Drugs

See prescription drug chart for tier information

Not covered
Chiropractic Services

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

$20
Diabetes Monitoring Supplies and Test Strips1

OneTouchTM and Accu-ChekTM test strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered.

$0 for up to a 90-day supply
Dialysis

Per treatment

20% of the cost

Diabetic Shoe Inserts

Copayment per pair

$10
Durable Medical Equipment

Such as insulin pumps, CPAP machines, prosthetic devices1

20% of the cost
Medicare-Covered Home Health Care Visits1
$0
Virtual Visits2

Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®2

$0
Hearing Aids2

Includes a three-year warranty with loss and damage insurance, up to six hearing aid follow up visits within three years and 16 batteries. Maximum of two hearing aids per year.

Select hearing aids discounted to
$795-$2,370 per device.
(A savings of up to $1,050 per hearing aid)
Additional Eyewear2

Discounts offered at EyeMed providers

Discounts included
SilverSneakers® Fitness2
Included
Over-the-Counter Coverage2

No rollover on quarterly allowance

$50 allowance per quarter
Pick Your Perks Reimbursement Program2
Not included 

Network PlatinumPlus (PPO) Drug Costs

Drug Deductible
This plan does not include drug coverage.
Initial Coverage
This plan does not include drug coverage.
Coverage Gap
This plan does not include drug coverage.
Catastrophic Coverage
This plan does not include drug coverage.

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.


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.