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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 a month

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  • Medical coverage for people who want control over their health care dollars with a medical savings account and high deductible health plan
  • $0 monthly premium
  • $1,500 deposited by Medicare in your Medicare Medical Savings Account
  • $5,400 medical deductible
  • Earn $180 in health rewards with the Ignite Wellness Program
  • You pay nothing for Medicare-covered services after you meet your deductible

Medical Savings Account (MSA) Plan Benefits

NetworkPrime (MSA) Benefits

Monthly Premium
$0
Annual Medical Deductible
$5,400
Annual Maximum Out-of-Pocket
$1,500
Primary Care Provider Visit
Until you meet your annual deductible of $5,400, 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 $5,400, 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 $5,400, 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.
Annual Medicare Wellness Visit
Until you meet your annual deductible of $5,400, 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 Vaccines

Flu, pneumonia, COVID-19

Until you meet your annual deductible of $5,400, 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.
Part B Vaccines

Hepatitis B, all other Part B vaccines

Until you meet your annual deductible of $5,400, 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 Hospital Services1

Per admission

Until you meet your annual deductible of $5,400, 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 Hospital Services
Until you meet your annual deductible of $5,400, 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.
Labs
Until you meet your annual deductible of $5,400, 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

Such as ultrasound, EKG, stress test

Until you meet your annual deductible of $5,400, 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 $5,400, 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 Services– Advanced Imaging
Until you meet your annual deductible of $5,400, 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 Visit
Until you meet your annual deductible of $5,400, 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
Until you meet your annual deductible of $5,400, 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.
Air and Ground Ambulance Services
Until you meet your annual deductible of $5,400, 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 $5,400, 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.
Physician Telehealth Services
Until you meet your annual deductible of $5,400, 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 Visit with MDLIVE®2

For medical (including dermatology) and mental health

Until you meet your annual deductible of $5,400, 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 B Drugs1
Until you meet your annual deductible of $5,400, 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.
Travel within the United States

Any doctor or hospital in the United States that accepts Medicare beneficiaries should accept your Network Prime plan.

Until you meet your annual deductible of $5,400, 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.
International Emergency Coverage

View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details

Not Included
Pick Your Perks2

Reimbursement for the following extra benefits: dental services, vision hardware ($200 maximum), healthy home-delivered meals, non-emergency transportation, over-the-counter items, acupuncture, massage therapy, personal training (four visits or $225 maximum, whichever happens first), nutritional/dietary counseling

Not Included
Preventive Dental Services2
Not Included
Medicare-Covered Dental Services

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

Until you meet your annual deductible of $5,400, 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 Comprehensive Dental Coverage2
$39 monthly premium
Annual Maximum: $1,000
Annual Routine Vision Exam2
Not Included
Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

Until you meet your annual deductible of $5,400, 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.
Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

Until you meet your annual deductible of $5,400, 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.
Over-the-Counter Coverage2
Not Included
Fitness with SilverSneakers®2
Not Included
Routine Hearing Exam2
Not Included
Diagnostic Hearing Exam
Until you meet your annual deductible of $5,400, 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

Maximum of two hearing aids per year
Hearing aid evaluation and fitting included

Not Included
Outpatient Mental Health

Individual or group therapy

Until you meet your annual deductible of $5,400, 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 $5,400, 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.
Opioid Treatment Services
Until you meet your annual deductible of $5,400, 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.
Substance Abuse Services

Outpatient individual or group therapy

Until you meet your annual deductible of $5,400, 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 $5,400, 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 Physical1, Occupational1, Speech Therapy
Until you meet your annual deductible of $5,400, 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 $5,400, 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 Acupuncture

For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year

Until you meet your annual deductible of $5,400, 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 $5,400, 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.
Chemotherapy1
Until you meet your annual deductible of $5,400, 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
Until you meet your annual deductible of $5,400, 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.
Acupuncture

Up to 12 visits per year are covered for members who are undergoing chemotherapy and experiencing nausea

Not Included
Home-Based Palliative Care
Not Included
Diabetes Monitoring Supplies and Test Strips

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 $5,400, 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 $5,400, 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.
Non-Emergency Transportation

24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)

Not Included
Dialysis
Until you meet your annual deductible of $5,400, 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.
*Includes abdominal aortic aneurysm screening, alcohol misuse screening and counseling, annual wellness visit, bone mass measurement, breast cancer screening, cardiovascular disease screening, cardiovascular disease risk reduction visit, cervical and vaginal cancer screening, colorectal cancer screening (screening colonoscopy, fecal occult blood test, flexible sigmoidoscopy), depression screening, diabetes screening, glaucoma screening, HIV screening, lung cancer screening, medical nutrition therapy services, Medicare Diabetes Prevention Program, obesity screening and therapy, prostate cancer screening, screening for sexually transmitted infections and counseling, smoking and tobacco use cessation counseling, one time Welcome to Medicare preventive visit
1Service may require prior authorization.

Network Prime (MSA) Drug Costs

Annual Drug Deductible
This plan does not include drug coverage
INITIAL COVERAGE Amount shown is the maximum you will pay, you may pay less.
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.