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Medicare Plans

Plan Details

Network PlatinumSelect (PPO)

Ideal for those who prefer no monthly premium and low copayments.

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Premium

$0 per month

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  • Same costs for in- and out-of-network providers
  • $0 medical deductible
  • $0 copayment for primary care provider visits 
  • $0 copayment for 90-day mail order Tier 1 drugs
  • $10 copayment for an annual eye exam
  • $90 emergency room visit
  • $4,900 maximum out-of-pocket (combined in- and out-of-network)
  • 100% coverage for preventive care
  • Prescription drug coverage
  • Travel coverage
  • Hearing aid discount benefit

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumSelect (PPO)

Services with a1 may require prior authorization.
2Visit networkhealth.com/medicare/additional-benefits for more information.
Monthly Premium
$0 per month (includes pharmacy)
Annual Medical Deductible
$0
Annual Maximum Out-of-Pocket

Combined in-and out-of-network (Does not include prescription drugs)

$4,900
Inpatient Hospital1

Per admission

$400 per day, Days 1-5 $0 Days 6 and beyond
Outpatient Surgery Services

$395

Primary Care Provider Visit
$0
Specialist Visit
$50
Preventive Care
$0
Emergency Room Visit 

Copayment is waived if admitted to a U.S. hospital within 24 hours

$90
Urgent Care
$50
Diagnostic Lab Tests
$0 -$20
X-rays
$30
Diagnostic Tests

Such as ultrasound, EKG, stress test

$40
Radiation Therapy1

Per service

20% of the cost
Diagnostic Radiology Services1

Such as MRIs, CT Scans

$200
Outpatient Ambulatory Surgical Center Services

Such as diagnostic colonoscopies 

$300
Preventive Dental Exam2
In-network: See Pick Your Perks Reimbursement Program
Out-of-network: See Pick Your Perks Reimbursement Program
Medicare-Covered Dental Services

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

$50
Comprehensive Dental Benefit2
$38 monthly premium Annual Maximum: $1,000
Routine Eye Exam2
$10 in-network, $40 reimbursement out-of-network 
Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

$50
Inpatient Mental Health1

Per admission

$395 per day, Days 1-4 $0 Days 5 and beyond
Outpatient Mental Health

Individual or group therapy

$40
Skilled Nursing Facility1

Per admission

$0 per day, Days 1-20, $184 per day, Days 21-57, $0 Days 58-100
Physical, Occupational, Speech Outpatient Therapy

Includes comprehensive outpatient rehabilitation facility.

$40
Ambulance - Air and Ground Services
$300
Transportation - Non-Emergency

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

Covered 
Medicare Part B Drugs and Chemotherapy1
20% of the cost
Medicare Part D Drugs

See prescription drug chart for tier information

Covered
Chiropractic Services

Manipulation of the spine to correct misalignment of one or more of the bones in your spine

$20
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.

$0 for up to a 90-day supply
Dialysis
20% of the cost
Diabetic Shoe Inserts

Copayment per pair

$10
Durable Medical Equipment

Such as insulin pumps, CPAP machines, prosthetic devices1

20% of the cost
Medicare-Covered Home Health Care Visits1
$0
Virtual Visits2

Virtual visit for medical (including dermatology) and behavioral health through MDLIVE®

$0
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

Up to $550 reimbursement. See Pick Your Perks Reimbursement Program, discounts also included.
SilverSneakers® Fitness2
Not included
Over-the-Counter Coverage2
Up to $550 reimbursement. See Pick Your Perks Reimbursement Program.
Pick Your Perks Reimbursement Program2

Reimbursement for Medicare-approved supplemental benefits including dental, vision, meals, non-emergency transportation, over-the-counter items, acupuncture, massage therapy expenses and nutritional/dietary benefits

$550 maximum reimbursement per year

Network PlatinumSelect (PPO) Drug Plan Costs

When your coverage starts, you have a $0 deductible for Tiers 1-3 
Drug Deductible
$395 for Tiers 4 and 5 only
Initial Coverage

30-Day Supply Preferred
Pharmacy or Mail Order Pharmacy
$2 for Tier 1     $42 for Tier 3
$8 for Tier 2      $90 for Tier 4
25% of the cost for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1     $47 for Tier 3
$14 for Tier 2   $100 for Tier 4
25% of the cost for Tier 5

90-Day Supply Preferred Pharmacy
$5 for Tier 1      $105 for Tier 3
$20 for Tier 2    $225 for Tier 4
Tier 5 is not available

90-Day Supply Standard Pharmacy
$10 for Tier 1     $118 for Tier 3
$35 for Tier 2     $250 for Tier 4
Tier 5 is not available

31 to 90-Day Mail Order Pharmacy
$0 for Tier 1

90-Day Mail Order Pharmacy
$0 for Tier 1     $105 for Tier 3
$20 for Tier 2     $225 for Tier 4
Tier 5 is not available

Coverage Gap
You enter the coverage gap when total drug costs reach $4,130. You pay 25% and Network Health pays 75% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.
Catastrophic Coverage
You enter catastrophic coverage when your true out-of-pocket costs reach $6,550. You pay the greater of $3.70 or 5% of the cost for generic drugs and $9.20 or 5% of the cost for brand name drugs.

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.