Skip to main content

Plan Details

Network Health PremierRx (PPO)

Ideal for those who prefer to pay a monthly premium and minimal copayments with prescription drug coverage.

_

Premium

$257

Enroll Now
Enroll Now
  • Same costs for in- and out-of-network providers (excluding annual routine vision, dental and hearing exams)
  • Annual maximum out-of-pocket of $3,400
  • $0 copayment for outpatient hospital services
  • $0 copayment for up to a 100-day supply for Tier 1 drugs at preferred retail and preferred mail order. $0 copayment for a 31- to 90-day supply for Tier 2 drugs at preferred mail order, after deductible.
  • One dental cleaning, exam and fluoride treatment per year for $30
  • Travel coverage
  • Medical and pharmacy coverage with a $257 monthly premium and a low maximum out-of-pocket
  • One Pass™ fitness benefit
  • $10 copayment for personal doctor (primary care provider) visits
  • $0 copayment for imaging services
  • $0 pharmacy deductible on Tier 1
  • 100% coverage for preventive care

Northeast Medicare Advantage PPO Plan Benefits

Network Health PremierRx (PPO)

Monthly Premium
$257
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
$10
Specialist Visit
$20
Preventive Care*
$0
Annual Medicare Wellness Visit
$0
Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

$0
Part B Vaccines

Hepatitis B1, all other Part B vaccines

$0
Inpatient Hospital Services1

Per admission

$75 per day, days 1-5
$0 days 6 and beyond
Outpatient Hospital Services1
$0
Ambulatory Surgical Center1
$0
Labs
$0
Diagnostic Tests1

Such as ultrasound, EKG, stress test

$0
Diagnostic Mammogram
$0
X-rays
$0
Diagnostic Radiology Services– Advanced Imaging1
$0
Urgent Care Visit
Free-standing facility
$20
Emergency Room Visit

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

$130
Air and Ground Ambulance Services
$0
Durable Medical Equipment

Such as insulin pumps1, CPAP machines, prosthetic devices1

$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 services

$0
Medicare Part B Drugs1
20% of the cost
Medicare Part D Drugs¹
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

$130 per incident
$100,000
Maximum benefit
Pick Your Perks2
Not available
Dental Services2
Preventive: 1 cleaning, exam and fluoride treatment 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

$0
Optional Comprehensive Dental Coverage2
$39 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

$0
Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

$0
Additional Eyewear2
Not covered
Over-the-Counter Catalog2
$75 per quarter
No rollover on quarterly allowance.
Fitness with One Pass™2
In-Network: $0
Routine Hearing Exam2
In-Network: $0
Diagnostic Hearing Exam

Exam to diagnose and treat hearing issues

$0
Fitting/Evaluation for Hearing Aids
In-Network: $0
Hearing Aids2

Maximum of two hearing aids per year
Hearing aid evaluation with TruHearing and fitting included in-network

In-Network: $495-$1,695 per device
Hearing aids must be purchased through TruHearing
Outpatient Mental Health

Individual or group therapy

$0
Inpatient Mental Health1

Per admission

$0
Opioid Treatment Services
$0
Substance Abuse Services

Outpatient individual or group therapy

$0
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
Medicare-Covered 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
$0
Chemotherapy1
20% of the allowed amount
Radiation Therapy1
Per service
$0
Diabetes Monitoring Supplies and Test Strips

Accu-Chek™ and FreeStyle™ test strips
FreeStyle Libre® and Dexcom® continuous glucose monitoring devices and supplies1 obtained through your pharmacy. Must have diabetic diagnosis. All other brands not covered.

$0 for up to a 90-day supply
Part B Insulin1

One month supply

No more than $35
Diabetic Shoe Inserts

Copayment per pair

$0
Dialysis

Per treatment

20% of the allowed amount
*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.

Network Health PremierRx (PPO) Drug Plan Costs

Annual Drug Deductible
$340
Applies to Tiers 2-5
INITIAL COVERAGE – Cost share applies after deductible is met. Amount shown is the maximum you will pay. You may pay less.

30-Day Supply
Preferred Pharmacy or Preferred Mail Order Pharmacy
$0 for Tier 1
$8 for Tier 2
22% for Tier 3
31% for Tier 4
29% for Tier 5

3-Month Supply
Preferred Pharmacy
100-day for Tier 1
90-day for Tier 2-4

$0 for Tier 1
$20 for Tier 2
22% for Tier 3
31% for Tier 4
Tier 5 is not available

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
22% for Tier 3
31% for Tier 4
Tier 5 is not available

30-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy
$8 for Tier 1
$17 for Tier 2
25% for Tier 3
31% for Tier 4
29% 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

$20 for Tier 1
$42 for Tier 2
25% for Tier 3
31% for Tier 4
Tier 5 is not available

Catastrophic Coverage
You enter catastrophic coverage when your total out-of-pocket costs reach $2,400. You pay $0.
Part D Insulin1
One-month supply
No more than $35
Part D Vaccines
Shingrix, RSV, all other adult vaccines recommended by the Advisory Committee on Immunization Practices
$0

This information is not a complete description of benefits. Call 800-378-5234 (TTY 711) 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.

Enroll Now