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Plan Details
Network PlatinumPremier Pharmacy (PPO)
Ideal for those who prefer travel and prescription drug coverage.
_Premium
$297 per month
Enroll Now- Same costs for in- and out-of-network providers
- $0 medical deductible
- $0 copayment for 90-day mail order Tier 1 drugs
- $10 for primary care provider visits
- $10 copayment for an in-network annual eye exam
- $75 for hospital stays days 1-5 and $0 for additional days
- $3,400 maximum out-of-pocket (combined in- and out-of-network)
- 100% coverage for preventive care
- Prescription drug coverage
- Travel coverage
- SilverSneakers® Fitness benefit
- Hearing aid discount benefit
- Annual dental exam and cleaning
Northeast Medicare Advantage PPO Plan Benefits
Network PlatinumPremier Pharmacy (PPO)
1Service may require prior authorization.
2Visitnetworkhealth.com/medicare/additional-benefits for more information.
Combined in-and out-of-network (Does not include prescription drugs)
Per admission
Copayment is waived if admitted to a U.S. hospital within 24 hours.
Such as ultrasound, EKGs, stress test
Per service
Such as MRIs, CT Scans
Such as diagnostic colonoscopies
One exam and cleaning per year, X-rays are not included
In-network: $30
Out-of-network: $100 reimbursement
Per admission
Individual or group therapy
Per admission
Includes comprehensive outpatient rehabilitation facility.
Includes 24 one-way trips for all members diagnosed with end stage renal disease (ESRD), to get to and from dialysis for treatment
See prescription drug chart for tier information
Manipulation of the spine to correct misalignment of one or more of the bones of your spine.
One Touch™ and Accu-Chek™ test strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered
Per treatment
Copayments per pair
Such as insulin pumps, CPAP machines, prosthetic devices1
Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®
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.
Discounts offered at EyeMed providers.
Network PlatinumPremier Pharmacy (PPO) Drug Plan Costs
30-Day Supply Preferred
Pharmacy or Mail Order Pharmacy
$2 for Tier 1 $42 for Tier 3
$8 for Tier 2 $90 for Tier 4
28% of the cost for Tier 5
30-Day Supply Standard Pharmacy
$4 for Tier 1 $47 for Tier 3
$14 for Tier 2 $100 for Tier 4
28% of the cost for Tier 5
90-Day Supply Preferred Pharmacy
$5 for Tier 1 $105 for Tier 3
$20 for Tier 2 $225 for Tier 4
Tier 5 is not available
90-Day Supply Standard Pharmacy
$10 for Tier 1 $118 for Tier 3
$35 for Tier 2 $250 for Tier 4
Tier 5 is not available
31 to 90-Day Supply Mail Order Pharmacy
$0 for Tier 1
90-Day Supply Mail Order Pharmacy
$0 for Tier 1 $105 for Tier 3
$20 for Tier 2 $225 for Tier 4
Tier 5 is not available
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.
