Medicare Plans

Plan Details

Network PlatinumPremier Pharmacy (PPO)

Ideal for those who prefer travel and prescription drug coverage.

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Premium

$296 per month

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  • 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)

Services with a 1 may require prior authorization.
Monthly Premium
$296 per month (includes pharmacy)
Annual Medical Deductible
This plan does not have a medical deductible.
Annual Maximum Out-of-Pocket

Combined in-and out-of-network

$3,400 per year combined, in- and out-of-network
Inpatient Hospital Coverage1

Per admission

$75 per day, Days 1-5 $0 Days 6 and beyond
Outpatient Surgery Services

including Ambulatory Surgical Center Services such as colonoscopies.

$0
Primary Care Provider
$10
Specialist
$20
Preventive Care
$0
Emergency Room

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

$120
Urgent Care
$0
Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization1
$0
X-rays
$0
Ultrasound, EKGs, EEGs, Stress Test
$0
Radiation Therapy1

Per service

$0
Diagnostic Radiology Services1

Such as MRIs, CT Scans

$0
Medicare Covered Hearing Exams

Diagnostic

$0
Medicare Covered Dental Exam

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

$0
Optional Dental Benefit with Delta Dental Medicare Advantage
$37 monthly premium Annual Maximum: $1,000
Medicare Covered Eye Exam
$0
Inpatient Mental Health1
$0 Days 1-90 $0 Days 91 and beyond
Outpatient Individual or Group Therapy, Psychiatric, Telehealth
$0
Skilled Nursing Facility1
$0
Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

$20
Ambulance
$0
Transportation
Not covered
Medicare Part B Drugs and Chemotherapy
20% of the cost
Medicare Part D Drugs
Covered
Chiropractic Care

Manipulation of the spine to correct when one or more of the bones in your spine move out of position.

$20
Diabetes Monitoring Supplies and Test Strips1

One Touch™ and Accu-Chek™ All other brands are not covered

$0 for up to a 90-day supply
Diabetes Self-Monitoring Training1
$0
Diabetic Shoes/Inserts
$0
Durable Medical Equipment Such as Insulin Pumps1 CPAP machines, Prosthetic Devices1
$0
Medicare Covered Home Health Care Visits1
$0
MDLIVE® Virtual Doctor Visits
$0
Hearing Aid Discount

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.

Select hearing aids discounted to
$1,220-$1,985 per device.
Save $775–$1,215 per hearing aid.
Non-Medicare Covered
Eyewear Discounts

offered at EyeMed providers.

Discounts included
SilverSneakers® Fitness
Included
Caregiver Support
Included
Over-the-Counter Coverage
Not included

Network PlatinumPremier Pharmacy (PPO) Drug Plan Costs

When your coverage starts, you have a $0 deductible for Tiers 1-3
Drug Deductible
$260 for Tiers 4 and 5 only
Initial Coverage

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

Coverage Gap
You enter the coverage gap when total drug costs reach $4,020. You pay 25% and Network Health pays 75% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.
Catastrophic Coverage
You enter catastrophic coverage when your true out-of-pocket costs reach $6,350. You pay the greater of $3.60 or 5% of the cost for generic drugs and $8.95 or 5% of the cost for brand name drugs.

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.


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.