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Plan Details
Network PlatinumPremier Pharmacy (PPO)
Ideal for those who prefer travel and prescription drug coverage.
_Premium
$296 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 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)
Combined in-and out-of-network
Per admission
including Ambulatory Surgical Center Services such as colonoscopies.
Copayment is waived if admitted to a U.S. hospital within 24 hours.
Per service
Such as MRIs, CT Scans
Diagnostic
Does not include services in connection with care, treatment, filling, removal or replacement teeth.
Includes comprehensive outpatient rehabilitation facility.
Manipulation of the spine to correct when one or more of the bones in your spine move out of position.
One Touch™ and Accu-Chek™ All other brands are not covered
Includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Maximum of two hearing aids per year.
$1,220-$1,985 per device.
Save $775–$1,215 per hearing aid.
Eyewear 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 $84 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 $91 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 $210 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 $228 for Tier 4
Tier 5 is not available
31 to 90-Day Mail Order Pharmacy
$0 for Tier 1
90-Day Mail Order Pharmacy
$0 for Tier 1 $105 for Tier 3
$20 for Tier 2 $210 for Tier 4
Tier 5 is not available
This information is not a complete description of benefits. Call 800-378-5237 (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.
