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Medicare Plans

Plan Details

Network PlatinumSelect (PPO)

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



$0 per month

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  • Same costs for in- and out-of-network providers
  • $0 medical deductible
  • $0 copayment for 90-day mail order Tier 1 drugs
  • $10 copayment for an annual eye exam
  • $15 copayment for primary care provider visits
  • $90 emergency room visit
  • $5,900 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 a 1 may require prior authorization.
Monthly Premium
$0 per month (includes pharmacy)
Annual Medical Deductible
This plan does not have a medical deductible.
Annual Maximum Out-of-Pocket

Combined in-and out-of-network

Inpatient Hospital Coverage1

Per admission

$450 per day, Days 1-4 $0 Days 5 and beyond

Outpatient Surgery Services

including Ambulatory Surgical Center Services such as colonoscopies.

Primary Care Provider
Preventive Care
Emergency Room

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

Urgent Care
Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization1
$0 -$20
Ultrasound, EKGs, EEGs, Stress Test
Radiation Therapy1

Per service

20% of the cost
Diagnostic Radiology Services1

Such as MRIs, CT Scans

Medicare Covered Hearing Exams


Medicare Covered Dental Exam

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

Optional Dental Benefit with Delta Dental Medicare Advantage
$37 monthly premium Annual Maximum: $1,000
Medicare Covered Eye Exam
Inpatient Mental Health1
$395 per day, Days 1-4 $0 Days 5 and beyond
Outpatient Individual or Group Therapy, Psychiatric, Telehealth
Skilled Nursing Facility1
$0 Days 1-20 $178 per day, days 21-57
Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

Not covered
Medicare Part B Drugs and Chemotherapy
20% of the cost
Medicare Part D Drugs
Chiropractic Care

Manipulation of the spine to correct when one or more of the bones in your spine move out of position.

Diabetes Monitoring Supplies and Test Strips1

One Touch™ and Accu-Chek™ All other brands are not covered

$0 for up to a 90-day supply
Diabetes Self-Monitoring Training1
Diabetic Shoes/Inserts
Durable Medical Equipment Such as Insulin Pumps1 CPAP machines, Prosthetic Devices1
20% of the cost
Medicare Covered Home Health Care Visits1
MDLIVE® Virtual Doctor Visits
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
Over-the-Counter Coverage
Not included

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      $84 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   $91 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    $210 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     $228 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     $210 for Tier 4
Tier 5 is not available

Coverage Gap
You enter the coverage gap when total drug costs reach $4,020. 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 $6,350. You pay the greater of $3.60 or 5% of the cost for generic drugs and $8.95 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
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.