NetworkPrime (MSA) Benefits
NetworkPrime (MSA)
Services with a 1 may require prior authorization.
Annual Medical Deductible
$5,100 per year
Annual Maximum Out-of-Pocket
Combined in-and out-of-network
$5,100
Inpatient Hospital Coverage1
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
including Ambulatory Surgical Center Services such as 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.
Primary Care Provider
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
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
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.
Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization1
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.
Ultrasound, EKGs, EEGs, Stress Test
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.
Medicare Covered Hearing Exams
Diagnostic
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 Exam
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.
Optional Dental Benefit with Delta Dental Medicare Advantage
$37 monthly premium Annual Maximum: $1,000
Medicare Covered Eye Exam
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
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 Individual or Group Therapy, Psychiatric, Telehealth
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
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 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
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
Not covered
Medicare Part B Drugs and Chemotherapy
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 Part D Drugs
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 Care
Manipulation of the spine to correct when one or more of the bones in your spine move out of position.
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™ 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.
Diabetes Self-Monitoring Training1
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 Shoes/Inserts
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 Pumps1 CPAP machines, Prosthetic Devices1
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.
MDLIVE® Virtual Doctor Visits
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 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
Not included
Caregiver Support
Included
Over-the-Counter Coverage
Not included
Virtual Visits
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