Network Health PremierRx (PPO)

Northeast Medicare Advantage PPO Plan Benefits

Network Health PremierRx (PPO)

Monthly Premium

$226

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

$10

Specialist Visit

$20

Preventive Care*

Annual Medicare Wellness Visit

Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

Part B Vaccines

Hepatitis B, all other Part B vaccines

Inpatient Hospital Services¹

Per admission

$75 per day, days 1-5
$0 days 6 and beyond

Outpatient Hospital Services¹

Ambulatory Surgical Center¹

Labs

Diagnostic Tests¹

Such as ultrasound, EKG, stress test

X-rays

Diagnostic Radiology Services– Advanced Imaging¹

Urgent Care Visit
Free-standing facility

$20

Emergency Room Visit

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

$125

Air and Ground Ambulance Services

Durable Medical Equipment

Such as insulin pumps¹, CPAP machines¹, prosthetic devices¹

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 Drugs

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

$125 per incident
$100,000
Maximum benefit

Pick Your Perks²

Not available

Dental Services²

Preventive: 1 cleaning and exam per year for $30
Out-of-Network: Up to $100 reimbursement

Medicare-Covered Dental Services

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

Optional Comprehensive Dental Coverage²

$45 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

Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

Additional Eyewear²

Not covered

Over-the-Counter Coverage²

Not covered

Fitness with One Pass^™²

Included

Routine Hearing Exam²

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

Diagnostic Hearing Exam

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

Inpatient Mental Health¹

Per admission

Opioid Treatment Services

Substance Abuse Services

Outpatient individual or group therapy

Skilled Nursing Facility¹

Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day

$0, days 1-100

Outpatient Physical¹, Occupational¹, Speech Therapy

$20

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

$20

Medicare-Covered Home Health Care Visits¹

Chemotherapy¹

20% of the cost

Radiation Therapy¹
Per service

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

One Touch^™ 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 Insulin

One month supply

20% of the cost, up to $35

Diabetic Shoe Inserts

Copayment per pair

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 cost

*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 PremierRx (PPO) Drug Plan Costs

Annual Drug Deductible

$310
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
$2 for Tier 1
$8 for Tier 2
21% for Tier 3
45% 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

$5 for Tier 1
$20 for Tier 2
21% for Tier 3
45% for Tier 4
Tier 5 is not available

31 to 100-Day Supply
Preferred Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2

$0 for Tier 1
$0 for Tier 2 after deductible

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
21% for Tier 3
45% for Tier 4
Tier 5 is not available

30-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy
$7 for Tier 1
$15 for Tier 2
22% for Tier 3
45% 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

$17 for Tier 1
$37 for Tier 2
22% for Tier 3
45% for Tier 4
Tier 5 is not available

Catastrophic Coverage

You enter catastrophic coverage when your total out-of-pocket costs reach $2,000. You pay $0.

Part D Insulin
One-month supply

$35

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

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.

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