NetworkPrime (MSA) Benefits
NetworkPrime (MSA)
2Visit networkhealth.com/medicare/additional-benefits for more information.
Annual Medical Deductible
$5,100 per year
Annual Maximum Out-of-Pocket
Combined in-and out-of-network
$5,100
Inpatient Hospital1
Per admission
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Outpatient Surgery Services
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Primary Care Provider Visit
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Specialist Visit
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Preventive Care
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Emergency Room Visit
Copayment is waived if admitted to a U.S. hospital within 24 hours.
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Urgent Care
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diagnostic Lab Tests
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
X-rays
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diagnostic Tests
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Radiation Therapy1
Per service
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diagnostic Radiology Services1
Such as MRIs, CT Scans
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Outpatient Ambulatory Surgical Center Services
Such as diagnostic colonoscopies
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Preventive Dental Exam2
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Medicare-Covered Dental Services
Does not include services in connection with care, treatment, filling, removal or replacement teeth.
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Comprehensive Dental Benefit2
$38 monthly premium Annual Maximum: $1,000
Routine Eye Exam2
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diagnostic Eye Exam
To diagnose and treat conditions of the eye
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Inpatient Mental Health1
Per admission
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Outpatient Mental Health
Individual or group therapy
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Skilled Nursing Facility1
Per admission
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Physical, Occupational, Speech Outpatient Therapy
Includes comprehensive outpatient rehabilitation facility.
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Ambulance - Air and Ground Services
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Transportation - Non-Emergency
Includes 24 one-way trips for all members diagnosed with end stage renal disease (ESRD), to get to and fro dialysis for treatment.
Not covered
Medicare Part B Drugs and Chemotherapy1
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Chiropractic Services
Manipulation of the spine to correct misalignment of one or more of the bones of your spine
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diabetes Monitoring Supplies and Test Strips1
One Touch™ and Accu-Chek™ test strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered.
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diabetic Shoe Inserts
Copayment per pair
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Durable Medical Equipment
Such as Insulin Pumps CPAP machines, Prosthetic Devices
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Medicare Covered Home Health Care Visits1
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Virtual Visits2
Virtual visit for medical (including dermatology) and behavioral health through MDLIVE
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Hearing Aids2
Includes a three-year warranty with loss and damage insurance, up to six hearing aid follow up visits within three years and 16 batteries. Maximum of two hearing aids per year.
Select hearing aids discounted to $795-$2,370 per device. A savings of up to $1,050 per hearing aid.
Additional Eyewear2
Discounts offered at EyeMed providers
Discounts included
SilverSneakers® Fitness2
Not included
Over-the-Counter Coverage2
No rollover on quarterly allowance
Not included
Pick Your Perks Reimbursement Program2
Virtual Visits
Find a Doctor
Find a Pharmacy
Look Up Medications
