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Medicare Plans

Plan Details

NetworkPrime (MSA)

Ideal for those who prefer no monthly premium and want to control their health care costs.

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Premium

$0 per month

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  • No monthly premium
  • $1,500 deposited by Medicare in your Medicare Medical Savings Account
  • $5,100 medical deductible, you pay nothing for Medicare-covered services after you meet your deductible
  • Earn up to $180 in rewards with the Ignite wellness Program

NetworkPrime (MSA) Benefits

NetworkPrime (MSA)

2Visit networkhealth.com/medicare/additional-benefits for more information.
Monthly Premium
$0
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.

Medicare Part D Drugs

Not covered

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.
Dialysis

Per treatment

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

Not included

Network Prime (MSA) Drug 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 800-378-5234 (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.