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Medicare Plans

Northeast Medicare Advantage
PPO
Plan Benefits

Network PlatinumSelect (PPO) Network PlatinumChoice (PPO) Network PlatinumPlus (PPO) Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO)
Premium $0 per month (includes pharmacy) $25 per month (includes pharmacy) $89 per month  $122 per month (includes pharmacy) $195 per month  $295 per month (includes pharmacy)
Deductible This plan does not have a medical deductible. This plan does not have a medical deductible. This plan does not have a medical deductible. This plan does not have a medical deductible. This plan does not have a medical deductible. This plan does not have a medical deductible.
Maximum Out-of-Pocket $5,900 per year combined, in- and out-of-network

$4,500 per year combined,

in- and out-of-network

$3,400 per year combined,

in- and out-of-network

$3,400 per year combined,

in- and out-of-network

$3,400 per year combined,

in- and out-of-network

$3,400 per year combined,

in- and out-of-network

Inpatient Hospital Coverage

Days 1-4: $450/day copayment

Days 5 and beyond: $0/day copayment

Days 1-4: $425/day copayment

Days 5 and beyond: $0/day copayment

Days 1-5: $375/day copayment

Days 6 and beyond: $0/day copayment

Days 1-5: $375/day copayment

Days 6 and beyond: $0/day copayment

Days 1-5: $75/day copayment

Days 6 and beyond: $0/day copayment

Days 1-5: $75/day copayment

Days 6 and beyond: $0/day copayment

Outpatient Surgery Services

$395 copayment

$395 copayment

$350 copayment

$350 copayment

$0 copayment

$0 copayment

Primary Care Provider

$15 copayment

$10 copayment

$15 copayment

$15 copayment

$10 copayment

$10 copayment

Specialist

$50 copayment

$50 copayment

$40 copayment

$40 copayment

$20 copayment

$20 copayment

Preventive Care

$0 copayment

$0 copayment

$0 copayment

$0 copayment

$0 copayment

$0 copayment

Emergency Room

$90 copayment

$90 copayment

$120 copayment

$120 copayment

$120 copayment

$120 copayment 

Urgent Care

$50 copayment

$45 copayment

$25 copayment

$25 copayment

$0 copayment

$0 copayment

Low Cost Labs

$0 copayment

$0 copayment

$0 copayment

$0 copayment

$0 copayment

$0 copayment

Lab and Clinical Diagnostic Tests

$20 copayment

$15 copayment

$5 copayment 

$5 copayment 

$0 copayment 

$0 copayment

Outpatient X-rays

$30 copayment

$30 copayment

$25 copayment

$25 copayment

$0 copayment 

$0 copayment

Ultrasound, EKGs, EEGs, Stress Test

$40 copayment

$35 copayment

$25 copayment

$25 copayment

$0 copayment

$0 copayment

Radiation Therapy

20%

$60 copayment

$60 copayment

$60 copayment

$0 copayment

$0 copayment

Diagnostic Radiology Services (Such as MRIs, CT Scans)

$150 copayment

$125 copayment

$100 copayment

$100 copayment

$0 copayment

$0 copayment

Medicare Covered Hearing Exams

$15 copayment

$10 copayment

$25 copayment

$25 copayment 

$0 copayment

$0 copayment

Medicare Covered Dental

$50 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

$50 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

$25 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

$25 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

$0 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

$0 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

Supplemental Dental

Not covered

One exam and cleaning per year with Delta Dental Medicare Advantage Provider. $30 copayment, no coverage out-of-network.

One exam and cleaning per year with Delta Dental Medicare Advantage Provider. $30 copayment, no coverage out-of-network.

One exam and cleaning per year with Delta Dental Medicare Advantage Provider. $30 copayment, no coverage out-of-network.

One exam and cleaning per year with Delta Dental Medicare Advantage Provider. $30 copayment, no coverage out-of-network.

One exam and cleaning per year with Delta Dental Medicare Advantage Provider. $30 copayment, no coverage out-of-network.

Medicare Covered Eye Exam

$50 copayment

$50 copayment

$25 copayment

$25 copayment

$0 copayment

$0 copayment

Supplemental Vision

$10 copayment in-network, maximum $30 reimbursement out-of-network

$10 copayment in-network, maximum $30 reimbursement out-of-network

$10 copayment in-network, maximum $30 reimbursement out-of-network

$10 copayment in-network, maximum $30 reimbursement out-of-network

$10 copayment in-network, maximum $30 reimbursement out-of-network

$10 copayment in-network, maximum $30 reimbursement out-of-network

Inpatient Mental Health Care

Days 1-4 $395 copayment/day

Days 5-190 $0 copayment including “lifetime reserve days” 

Days 1-4 $295 copayment/day

Days 5-190 $0 copayment  including “lifetime reserve days” 

Days 1-10 $150 copayment/day

Days 11-190 $0 copayment  including “lifetime reserve days” 

Days 1-10 $150 copayment/day

Days 11-190 $0 copayment/day including “lifetime reserve days” 

Days 1-190 $0 copayment/day including “lifetime reserve days”

Days 1-190 $0 copayment/day including “lifetime reserve days”

Outpatient Mental Health Care

Individual or group therapy

$40 copayment

Individual or group therapy

$40 copayment

Individual or group therapy

$35 copayment

Individual or group therapy

$35 copayment

Individual or group therapy

$0 copayment

Individual or group therapy

$0 copayment

Skilled Nursing Facility

Days 1-20 $0 copayment/day

Days 21-57 $172 copayment/day

Days 58-100 $0 copayment

Days 1-20 $0 copayment/day

Days 21-49 $172 copayment/day

Days 50-100 $0 copayment

Days 1-20 $20 copayment/day

Days 21-54 $172 copayment/day

Days 55-100 $0 copayment

Days 1-20 $20 copayment/day

Days 21-54 $172 copayment/day

Days 55-100 $0 copayment

Days 1-100 $0 copayment/day

Days 1-100 $0 copayment/day

Physical Therapy

$40 copayment

$40 copayment

$40 copayment

$40 copayment

$20 copayment

$20 copayment

Ambulance

$300 copayment

$275 copayment

$250 copayment

$250 copayment

$0 copayment

$0 copayment

Transportation

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Medicare Part B Drugs and Chemotherapy

20%

20%

20%

20%

20%

20%

Medicare Part D Drugs

Covered

Covered 

Not covered

Covered 

 Not covered

Covered

Chiropractic Care

$20 copayment for manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

$20 copayment for manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

$20 copayment for manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

$20 copayment for manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

$20 copayment for manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

$20 copayment for manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

Diabetes Monitoring Supplies and Test Strips1

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a
90-day supply

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a
90-day supply

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a
90-day supply
 

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a
90-day supply

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a 90-day supply

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a 90-day supply

Diabetes Self-Monitoring Training

$0 copayment

$0 copayment

$0 copayment 

$0 copayment 

$0 copayment 

$0 copayment

Theraputic Shoes/Inserts

$10 copayment

$10 copayment 

$10 copayment 

$10 copayment 

$0 copayment 

$0 copayment 

Prosthetic Devices

20% of the cost

20% of the cost

20% of the cost

20% of the cost 

$0 copayment 

$0 copayment  

Related Medical Supplies

20% of the cost

20% of the cost

20% of the cost

20% of the cost

$0 copayment  

$0 copayment  

Home Health Care

$0 copayment

$0 copayment 

$0 copayment 

$0 copayment 

$0 copayment 

$0 copayment 

Drug Deductible

$395 For tiers 3, 4 and 5 only

$260 For tiers 3, 4 and 5 only

 

$260 For tiers 3, 4 and 5 only

 

$260 For tiers 3, 4 and 5 only

Initial Drug Coverage

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy

  • $2 for Tier 1
  • $8 for Tier 2
  • $42 for Tier 3
  • $84 for Tier 4
  • 25% for Tier 5

30-Day Supply Standard Pharmacy

  • $4 for Tier 1
  • $14 for Tier 2
  • $47 for Tier 3
  • $91 for Tier 4
  • 25% for Tier 5

90-Day Supply Preferred Pharmacy

  • $5 for Tier 1
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

90-Day Supply Standard Pharmacy

  • $10 for Tier 1
  • $35 for Tier 2
  • $118 for Tier 3
  • $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
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy

  • $2 for Tier 1
  • $8 for Tier 2
  • $42 for Tier 3
  • $84 for Tier 4
  • 28% for Tier 5

30-Day Supply Standard Pharmacy

  • $4 for Tier 1
  • $14 for Tier 2
  • $47 for Tier 3
  • $91 for Tier 4
  • 28% for Tier 5

90-Day Supply Preferred Pharmacy

  • $5 for Tier 1
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

90-Day Supply Standard Pharmacy

  • $10 for Tier 1
  • $35 for Tier 2
  • $118 for Tier 3
  • $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
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy

  • $2 for Tier 1
  • $8 for Tier 2
  • $42 for Tier 3
  • $84 for Tier 4
  • 28% for Tier 5

30-Day Supply Standard Pharmacy

  • $4 for Tier 1
  • $14 for Tier 2
  • $47 for Tier 3
  • $91 for Tier 4
  • 28% for Tier 5

90-Day Supply Preferred Pharmacy

  • $5 for Tier 1
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

90-Day Supply Standard Pharmacy

  • $10 for Tier 1
  • $35 for Tier 2
  • $118 for Tier 3
  • $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
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy

  • $2 for Tier 1
  • $8 for Tier 2
  • $42 for Tier 3
  • $84 for Tier 4
  • 28% for Tier 5

 

30-Day Supply Standard Pharmacy

  • $4 for Tier 1
  • $14 for Tier 2
  • $47 for Tier 3
  • $91 for Tier 4
  • 28% for Tier 5

 

90-Day Supply Preferred Pharmacy

  • $5 for Tier 1
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

 

90-Day Supply Standard Pharmacy

  • $10 for Tier 1
  • $35 for Tier 2
  • $118 for Tier 3
  • $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
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

 

Coverage Gap

You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

 

Catastrophic Coverage

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

 

Southeast Medicare Advantage
PPO Plan Benefits
Network Health Medicare Go (PPO) Network Health Medicare Anywhere (PPO)
Premium $0 per month (includes pharmacy) $25 per month (includes pharmacy)
Deductible This plan does not have a medical deductible. This plan does not have a medical deductible.

Maximum Out-of-Pocket

$5,900 per year combined, in- and out-of-network $4,500 per year combined, in- and out-of-network
Inpatient Hospital Coverage

In-network: Days 1-4 $395/day copayment
Days 5 and beyond $0 copayment
Out-of-network: Days 1-5 $395/day copayment
Days 6 and beyond $0 copayment

In-network: Days 1-4 $295/day copayment
Days 5 and beyond $0 copayment
Out-of-network: Days 1-4 $395
Days 5 and beyond $0 copayment

Outpatient Surgery Services

In- and Out-of-network: $395 copayment

In-network: $295 copayment
Out-of-network: $395 copayment

Primary Care Provider

In-network: $10 copayment
Out-of-network: $20 copayment

In-network: $5 copayment
Out-of-network: $15 copayment

Specialist

In-network: $45 copayment
Out-of-network: $55 copayment

In-network: $45 copayment
Out-of-network: $55 copayment

Preventive Care

In-network: $0 copayment
Out-of-network: $15 copayment

In-network: $0 copayment
Out-of-network: $15 copayment

Emergency Room

In- and Out-of-network: $90 copayment

In- and Out-of-network: $90 copayment

Urgent Care

In- and Out-of-Network: $45 copayment

In- and Out-of-Network: $45 copayment

Low Cost Labs

In-network: $0 copayment
Out-of-network: $30 copayment

In-network: $0 copayment
Out-of-network: $25 copayment

Lab and Clinical Diagnostic Tests

In-network: $20 copayment
Out-of-network: $30 copayment

In-network: $20 copayment
Out-of-network: $25 copayment

Outpatient X-rays

In-network: $35 copayment
Out-of-network: $45 copayment

In-network: $20 copayment
Out-of-network: $45 copayment

Ultrasound, EKGs, EEGs, Stress Test

In-network: $40 copayment
Out-of-network: $50 copayment

In-network: $35 copayment
Out-of-network: $45 copayment

Radiation Therapy

In-network: 20%, Out-of-network: 25%

In-network: 20%, Out-of-network: 25%

Diagnostic Radiology Services (Such as MRIs, CT Scans)

In-network: $125 copayment
Out-of-network: $140 copayment

In-network: $125 copayment
Out-of-network: $140 copayment

Medicare Covered Hearing Exams

In-network: $15 copayment
Out-of-network: $25 copayment

In-network: $10 copayment
Out-of-network: $25 copayment

Medicare Covered Dental

In-network: $50 copayment
Out-of-network: $55 copayment
(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

In-network: $50 copayment
Out-of-network: $55 copayment
(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

Supplemental Dental

Not covered

One exam and cleaning per year with Delta Dental Medicare Advantage Provider.
In-network: $30 copayment
Out-of-network: No coverage

Medicare Covered Eye Exam

In-network: $50 copayment
Out-of-network: $55 copayment

In-network: $50 copayment
Out-of-network: $55 copayment

Supplemental Vision

In-network: $10 copayment
Out-of-network: maximum $30 reimbursement

In-network: $10 copayment
Out-of-network: maximum $30 reimbursement

 

Inpatient Mental Health Care

In-network: Days 1-3 $395 copayment/day
Days 4-190 $0 copayment including “lifetime reserve days”

Out-of-network: Days 1-4 $395 copayment/day
Days 5-190 $0 copayment including “lifetime reserve days”

In-network: Days 1-4 $295 copayment/day
Days 5-190 $0 copayment including “lifetime reserve days”

Out-of-network: Days 1-3 $395 copayment/day
Days 4-190 $0 copayment including “lifetime reserve days”

 

Outpatient Mental Health Care

In-network: Individual or group therapy
$40 copayment

Out-of-network: $50 copayment

In-network: Individual or group therapy
$40 copayment

Out-of-network: $50 copayment

Skilled Nursing Facility

In- and Out-of-network:
Days 1-20 $0 copayment/day
Days 21-57 $172 copayment/day
Days 58-100 $0 copayment

In- and Out-of-network:
Days 1-20 $0 copayment/day
Days 21-49 $172 copayment/day
Days 50-100 $0 copayment

Physical Therapy

In-network: $40 copayment

Out-of-network: $50 copayment

In-network: $40 copayment

Out-of-network: $50 copayment

Ambulance

In- and Out-of-network: $275 copayment

In- and Out-of-network: $250 copayment

Transportation

Not covered

Not covered

Medicare Part B Drugs and Chemotherapy

In-network: 20%

Out-of-network: 25%

In-network: 20%

Out-of-network: 25%

Medicare Part D Drugs

Covered

Covered 

Chiropractic Care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):

In-network: $20 copayment

Out-of-network: $50 copayment

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):

In-network: $20 copayment

Out-of-network: $50 copayment

Diabetes Monitoring Supplies and Test Strips1

One Touch™ and Accu-Chek™ (All other brands are not covered)
$0 copayment, applies up to a 90-day supply

One Touch™ and Accu-Chek™ (All other brands are not covered)
$0 copayment, applies up to a 90-day supply

Diabetes Self-Monitoring Training

In- and Out-of-network: $0 copayment

In- and Out-of-network: $0 copayment

Theraputic Shoes/Inserts

In- and Out-of-network: $10 copayment

In- and Out-of-network: $10 copayment

Prosthetic Devices

In-network: 20% of the cost

Out-of-network: 25%

In-network: 20% of the cost

Out-of-network: 25%

Related Medical Supplies

In-network: 20% of the cost

Out-of-network: 25%

In-network: 20% of the cost

Out-of-network: 25%

Home Health Care

In-network: $0 copayment

Out-of-network: $15 copayment

In-network: $0 copayment

Out-of-network: $15 copayment

Drug Deductible

$275 For tiers 3, 4 and 5 only

 $250 For tiers 3, 4 and 5 only

Initial Coverage

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy

  • $2 for Tier 1
  • $8 for Tier 2
  • $42 for Tier 3
  • $84 for Tier 4
  • 27% for Tier 5

 30-Day Supply Standard Pharmacy

  • $4 for Tier 1
  • $14 for Tier 2
  • $47 for Tier 3
  • $91 for Tier 4
  • 27% for Tier 5

 90-Day Supply Preferred Pharmacy

  • $5 for Tier 1 
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

90-Day Supply Standard Pharmacy

  • $10 for Tier 1
  • $35 for Tier 2
  • $118 for Tier 3
  • $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    
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy

  • $2 for Tier 1
  • $8 for Tier 2
  • $42 for Tier 3
  • $84 for Tier 4
  • 28% for Tier 5

30-Day Supply Standard Pharmacy

  • $4 for Tier 1
  • $14 for Tier 2
  • $47 for Tier 3
  • $91 for Tier 4
  • 28% for Tier 5

90-Day Supply Preferred Pharmacy

  • $5 for Tier 1 
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

 90-Day Supply Standard Pharmacy

  • $10 for Tier 1
  • $35 for Tier 2
  • $118 for Tier 3
  • $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    
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available
Coverage Gap

You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

Catastrophic Coverage

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

 

NetworkPrime MSA
Benefits
NetworkPrime (MSA)
Premium

You pay nothing for your Medicare monthly plan premium. Medicare pays this monthly plan premium. You must keep paying your Medicare Part B premium.

Maximum Out-of-Pocket

$5,100

Deductible

$5,100 per year - you will pay nothing for Medicare-covered services after you meet your deductible

Inpatient Hospital Coverage

You pay nothing after you meet your deductible. 
Our plan covers 90 days for an inpatient hospital stay. 
Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. Once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.
Once you meet your deductible, the plan pays 100% of Medicare-approved costs. 

Outpatient Surgery Services

You pay nothing after you meet your deductible.

Covered services include:
• Ambulatory surgical center
• Outpatient hospital

Primary Care Provider

You pay nothing after you meet your deductible.

Specialist

You pay nothing after you meet your deductible.

Preventive Care

You pay nothing after you meet your deductible. 
Until you meet your yearly deductible, you pay up to 100% for the Medicare-approved amount.

Emergency Room

You pay nothing after you meet your deductible

Urgent Care

You pay nothing after you meet your deductible

Low Cost Labs

You pay nothing after you meet your deductible

Lab and Clinical Diagnostic Tests

You pay nothing after you meet your deductible

Outpatient X-rays

You pay nothing after you meet your deductible

Ultrasound, EKGs, EEGs, Stress Test

You pay nothing after you meet your deductible

Radiation Therapy

You pay nothing after you meet your deductible

Diagnostic Radiology Services (Such as MRIs, CT Scans)

You pay nothing after you meet your deductible

Medicare Covered Hearing Exams

You pay nothing after you meet your deductible

Medicare Covered Dental

You pay nothing after you meet your deductible.

Limited to Medicare-covered dental services only. Medicare does not cover services in connection with care, treatment, filling, removal, or replacement of teeth.

Supplemental Dental

Not covered

Medicare Covered Eye Exam

You pay nothing after you meet your deductible.

Covered services include:
• Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening)
• Eyeglasses or contact lenses after cataract surgery

Supplemental Vision

Not covered

Inpatient Mental Health Care

You pay nothing after you meet your deductible.

Covered services include:
• Inpatient visit - Up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental health services provided in a general hospital.

Outpatient Mental Health Care

You pay nothing after you meet your deductible.

Covered services include:
• Outpatient group therapy visit
• Outpatient individual therapy visit

Skilled Nursing Facility

You pay nothing after you meet your deductible.
 
Covered services include up to 100 days in a skilled nursing facility

Physical Therapy

You pay nothing after you meet your deductible.

Covered services include:
• Occupational therapy visit
• Physical therapy and speech and language therapy visit

Ambulance

You pay nothing after you meet your deductible

Transportation

Not covered

Medicare Part B Drugs and Chemotherapy

You pay nothing after you meet your deductible.

• For Part B drugs such as chemotherapy drugs
• Other Part B drugs

Medicare Part D Drugs

Not included

Chiropractic Care

You pay nothing after you meet your deductible. 

Chiropractic Care is limited to Manual Manipulation of the spine to correct a subluxation when 1 or more of the bones of your spine move out of position

Diabetes Monitoring Supplies and Test Strips1

You pay nothing after you meet your deductible

Diabetes Self-Monitoring Training

You pay nothing after you meet your deductible

Theraputic Shoes/Inserts

 You pay nothing after you meet your deductible

Durable Medical Equipment

You pay nothing after you meet your deductible

Prosthetic Devices

You pay nothing after you meet your deductible

Related Medical Supplies

You pay nothing after you meet your deductible

Home Health Care

You pay nothing after you meet your deductible

Drug Deductible
Initial Drug Coverage
Coverage gap
Catastrophic Coverage
Network Health Medicare
Explore HMO Benefits
Network Health Medicare Explore (HMO)
Premium

$35 per month (Includes pharmacy)

Deductible

This plan does not have a medical deductible.

Maximum Out-of-Pocket

$4,900 per year

Inpatient Hospital Coverage

Days 1-6 $295/day copayment
Days 7 and beyond $0 copayment

Outpatient Surgery Services

$295 copayment

Primary Care Provider

$0 copayment

Specialist

$30 copayment

Preventive Care

$0 copayment

Emergency Room

$90 copayment

Urgent Care

$45 copayment

Low Cost Labs

$0 copayment

Lab and Clinical Diagnostic Tests

$15 copayment

Outpatient X-rays

$25 copayment

Ultrasound, EKGs, EEGs, Stress Test

$35 copayment

Radiation Therapy

$60 copayment

Diagnostic Radiology Services (Such as MRIs, CT Scans)

$125 copayment

Medicare Covered Hearing Exams

$10 copayment

Medicare Covered Dental

$50 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

Supplemental Dental

One exam and cleaning per year with Delta Dental Medicare Advantage Provider.
$30 copayment

Medicare Covered
Eye Exam

$50 copayment

Supplemental Vision

$10 copayment, maximum $30 reimbursement out-of-network

Inpatient Mental Health Care

Days 1-5 $295 copayment/day
Days 6-190 $0 copayment including “lifetime reserve days”

Outpatient Mental Health Care

Individual or group therapy $30 copayment

Skilled Nursing Facility

Days 1-20 $0 copayment/day
Days 21-49 $172 copayment/day
Days 50-100 $0 copayment

Physical Therapy

$30 copayment

Ambulance

$225 copayment

Transportation

Not covered

Medicare Part B Drugs and Chemotherapy

20% of the cost

Medicare Part D Drugs

Covered

Chiropractic Care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
$20 copayment

Diabetes Monitoring Supplies and Test Strips1

One Touch™ and Accu-Chek™
(All other brands are not covered)
$0 copayment, applies up to a 90-day supply

Diabetes Self-Monitoring Training

$0 copayment

Theraputic Shoes/Inserts

$10 copayment

Durable Medical Equipment

 

Prosthetic Devices

20% of the cost

Related Medical Supplies

20% of the cost

Home Health Care

$0 copayment

Drug Deductible

$260 for tiers 3, 4 and 5 only

Initial Drug Coverage

30-Day Supply Preferred Pharmacy or Mail Order Pharmacy

  • $2 for Tier 1
  • $8 for Tier 2
  • $42 for Tier 3
  • $84 for Tier 4
  • 28% for Tier 5

30-Day Supply Standard Pharmacy

  • $4 for Tier 1
  • $14 for Tier 2
  • $47 for Tier 3
  • $91 for Tier 4
  • 28% for Tier 5

90-Day Supply Preferred Pharmacy

  • $5 for Tier 1 
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available

90-Day Supply Standard Pharmacy

  • $10 for Tier 1
  • $35 for Tier 2
  • $118 for Tier 3
  • $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    
  • $20 for Tier 2
  • $105 for Tier 3
  • $210 for Tier 4
  • Tier 5 is not available
Coverage gap You enter the coverage gap when total drug costs reach $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%
Catastrophic Coverage You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.
Network Health (PPO SNP)

 NetworkCares Benefits

 Medicaid Benefits 

Premium

$0 per month. In addition, you must keep paying your Medicare Part B premium.

 Premiums, deductibles and payment limitations depend on the type of coverage you have. For benefit questions, contact

Forward Health Member Services at 800-362-3002 or consult your Forward Health Enrollment and Benefits Handbook.

Deductible

This plan has deductibles for some hospital and medical services.

$0–$1,340 per year for inpatient hospital services and $0–$183 from in-network and out-of-network providers, depending on your level of Medicaid eligibility. These amounts may change for 2019.

$0–$400 per year for Part D prescription drugs.

Premiums, deductibles and payment limitations depend on the type of coverage you have. For benefit questions, contact

Forward Health Member Services at 800-362-3002 or consult your Forward Health Enrollment and Benefits Handbook.

Maximum Out-of-Pocket

Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.

In this plan, you may pay nothing for some services, depending on your level of Wisconsin Medicaid eligibility.

Your yearly limit(s) in this plan:

$6,700 for services you receive from in-network providers

$10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.

If you reach the limit on out-of-pocket costs, you may continue getting your covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Premiums, deductibles and payment limitations depend on the type of coverage you have. For benefit questions, contact

Forward Health Member Services at 800-362-3002 or consult your Forward Health Enrollment and Benefits Handbook.

 

Inpatient Hospital Coverage

The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

In- and out-of-network: In 2018 the amounts for each benefit period were:

• $0 - $1,340 deductible

• $0 copayment for days 1 through 60

• $335 copayment per day for days 61 through 90

• $670 copayment per day for 60 lifetime reserve days

These amounts may change for 2019.

Full coverage
$3 copayment per day with a $75 cap per stay

 

Outpatient Surgery Services

Ambulatory surgical center:
• In- and out-of-network: 0% - 20% of the cost

Outpatient hospital:
• In- and out-of-network: 0% - 20% of the cost

Full coverage
$3 copayment per visit

 

Primary Care Provider

• In- and out-of-network: 0% - 20% of the cost

Full coverage
$0.50 to $3 copayment per service

Specialist

• In- and out-of-network: 0% - 20% of the cost

Full coverage
$0.50 to $3 copayment per service

Preventive Care

• In-network: 0% of the cost

• Out-of-network: 0% - 20% of the cost of the cost

Our plan covers many preventive services, including:

Abdominal aortic aneurysm screening

Alcohol misuse counseling

Bone mass measurement

Breast cancer screening (mammogram)

Cardiovascular disease (behavioral therapy)

Cardiovascular screenings

Cervical and vaginal cancer screening

Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy)

Depression screening

Diabetes screenings

HIV screening

Medical nutrition therapy services

Medicare Diabetes Prevention Program (MDPP)

Obesity screening and counseling

Prostate cancer screenings (PSA)

Sexually transmitted infections screening and counseling

Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

Vaccines, including flu shots, hepatitis B shots, pneumococcal shots

“Welcome to Medicare” preventive visit (one-time)

Yearly “Wellness” visit

Emergency care received in the United States and its territories

Urgently needed care received inside the United States and its territories

Any additional preventive services approved by Medicare during the contract year will be covered.

Annual physical exam:

• In-network: $0 copayment

• Out-of-network: 0% - 20% of the cost

Full coverage

 

Emergency Room

• In- and out-of-network: 0% - 20% of the cost (up to $90)

If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care.
See the “Inpatient Hospital Care” section of this booklet for other costs.

Full coverage

 

Urgent Care

Urgent Care Walk-In Clinic:
• In- and out-of-network: 0% - 20% of the cost

Full coverage, including laboratory and radiology
$0.50 to $3 copayment per service, limited to $30 per provider per calendar year.

No copayment for preventive services, emergency services, anesthesia or clozapine management.

Low Cost Labs

• In- and out-of-network: 0% - 20% of the cost

 

 Full coverage

Lab and Clinical Diagnostic Tests

• In- and out-of-network: 0% - 20% of the cost

 Full coverage

Outpatient X-rays

• In- and out-of-network: 0% - 20% of the cost

 Full coverage

Ultrasound, EKGs, EEGs, Stress Test

• In- and out-of-network: 0% - 20% of the cost

 Full coverage

Radiation Therapy

Therapeutic radiology services (such as radiation treatment for cancer):
• In- and out-of-network: 0% - 20% of the cost

Full coverage 

Diagnostic Radiology Services
(Such as MRIs, CT Scans)

• In- and out-of-network: 0% - 20% of the cost

 Full coverage 

Medicare Covered Hearing Exams

Exam to diagnose and treat hearing and balance issues:
• In- and out-of-network: 0% - 20% of the cost

A hearing aid discount is offered with Simpli Hearing, LLC to NetworkCares members. Call Network Health for more information.

Full coverage
$.50 to $3 copayment per procedure

No copayment for hearing aid batteries

Medicare Covered Dental

Visit medicareadvantage.deltadentalwi.com for a list of in-network dentists.

Limited dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth):

• In- and out-of-network: 0% - 20% of the cost

Preventive dental services:

Cleaning (twice a year):

• In- and out-of-network: $0 copayment

Dental x-ray(s) (bitewing 1 per year, full mouth 1 every 5 years):

• In- and out-of-network: $0 copayment

Oral exam (twice a year):

• In- and out-of-network: $0 copayment

Basic Restorative Services:

• In- and out-of-network: 0% of the cost

Major Services (endodontics/periodontics/extractions, prosthodontics, other oral/maxillofacial surgery, other services): 
• In- and out-of-network: 0% - 50% of the cost

Our plan pays up to $3,000 every year for most dental services.

Full coverage

$.50 to $3 copayment per service

 

Supplemental Dental

Not covered

 

Medicare Covered
Eye Exam

Visit eyemedvisioncare.com for a list in-network providers. Select the Insight network.

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):

• In- and out-of-network: 0% - 20% of the cost

Routine eye exam (for up to 1 every year):

• In-network: $0

• Out-of-network: Eye Med will reimburse up to $30

Eyeglasses or contact lenses after cataract surgery:

• In- and out-of-network: 0% - 20% of the cost

Our plan pays up to $500 in-network or $400 out-of-network  annually for contact lenses and/or glasses with a valid prescription, including enhancements.

Routine Vision - full coverage including

coverage of eyeglasses.

$0.50 to $3 copayment per service

 

Supplemental Vision

Not covered

 

Inpatient Mental Health Care

Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental services provided in a general hospital.

The copayments for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days up to a total 190 lifetime days.

In- and out-of-network: In 2018 the amounts for each benefit period were:

• $0 - $1,340 deductible

• $0 copayment for days 1 - 60

• $0 - $335 copayment per day for days 61 through 90

• $0 - $670 copayment per day for 60 lifetime reserve days

These amounts may change for 2019.

Full coverage (not including room and board)

$.50 to $3 copayment per service, limited to the first 15 hours or $825 of services, whichever comes first, provided per calendar year. Copayment is not required when services are provided in a hospital setting.

 

Outpatient Mental Health Care

These amounts may change for 2019.

Outpatient group therapy visit:

In- and out-of-network: 0% - 20% of the cost

Outpatient individual therapy visit:

In- and out-of-network: 0% - 20% of the cost

 Full coverage (not including room and board)

$.50 to $3 copayment per service, limited to the first 15 hours or $825 of services, whichever comes first, provided per calendar year. Copayment is not required when services are provided in a hospital setting.

Skilled Nursing Facility

Our plan covers up to 100 days in a SNF.

In- and out-of-network: In 2018 the amounts for each benefit period were:

• $0 copayment for days 1 through 20

• $0 - $167.50 copayment per day for days 21 through 100

These amounts may change for 2019. A prior three-day inpatient hospital stay is required.

Full coverage
No copayment

 

Physical Therapy

In- and out-of-network: 0% - 20% of the cost

 

Ambulance

In- and out-of-network: 0% - 20% of the cost

 Full coverage of emergency transportation to and from a certified provider for a covered service.

Transportation

Not covered

 

Medicare Part B Drugs
and Chemotherapy

In- and out-of-network: 0% - 20% of the cost

 

Medicare Part D Drugs

Covered

 

Chiropractic Care

Manual manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):

In- and out-of-network: 0% - 20% of the cost

Full coverage
$.50 to $3 copayment per service

 

Diabetes Monitoring Supplies
and Test Strips1

In- and out-of-network: 0% - 20% of the cost

Full coverage

$.50 to $3 copayment per service and $.50 per prescription for diabetic supplies

Diabetes Self-Monitoring Training

In- and out-of-network: 0% - 20% of the cost

 Full coverage

$.50 to $3 copayment per service and $.50 per prescription for diabetic supplies

Theraputic Shoes/Inserts

In- and out-of-network: 0% - 20% of the cost

 Full coverage

$.50 to $3 copayment per service and $.50 per prescription for diabetic supplies

Durable Medical Equipment

In- and out-of-network: 0% - 20% of the cost

 Full coverage

Prosthetic Devices

In- and out-of-network: 0% - 20% of the cost

 Full coverage

Related Medical Supplies

In- and out-of-network: 0% - 20% of the cost

 Full coverage

Home Health Care

In- and out-of-network: $0 copayment

 Full coverage

Drug Deductible

For Part B drugs such as chemotherapy drugs1:

In- and out-of-network: 0% - 20% of the cost

Other Part B drugs1:

In- and out-of-network: 0% - 20% of the cost

Part D Prescription Drug Deductible on Tiers 1 - 5: $0 - $400

Comprehensive drug benefit with coverage of generic and brand name prescription drugs and some over-the-counter (OTC) drugs

 

Initial Drug Coverage

 

Coverage gap
Catastrophic Coverage

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.