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Medicare Plans

Plan Details

Network PlatinumPremier (PPO)

Ideal for those who prefer travel coverage.

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Premium

$195 per month

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  • $0 medical deductible
  • $10 copayment 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
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Hearing aid discount benefit
  • Annual dental exam and cleaning

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPremier (PPO)

Services with a 1 may require prior authorization.
Monthly Premium
$195
Annual Medical Deductible
This plan does not have a medical deductible.
Annual Maximum Out-of-Pocket

Combined in-and out-of-network

$3,400
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
Not 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 (PPO) Drug Plan Costs

Drug Deductible
This plan does not include drug coverage
Initial Coverage
This plan does not include drug coverage
Coverage Gap
This plan does not include drug coverage
Catastrophic Coverage
This plan does not include drug coverage

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.