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Northeast Medicare Advantage |
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™ |
One Touch™ and Accu-Chek™ |
One Touch™ and Accu-Chek™ |
One Touch™ and Accu-Chek™ |
One Touch™ and Accu-Chek™ |
One Touch™ and Accu-Chek™ |
| 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 |
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$260 For tiers 3, 4 and 5 only |
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$260 For tiers 3, 4 and 5 only |
| Initial Drug Coverage |
30-Day Supply Preferred Pharmacy or Mail Order Pharmacy
30-Day Supply Standard Pharmacy
90-Day Supply Preferred Pharmacy
90-Day Supply Standard Pharmacy
31 to 90-Day Mail Order Pharmacy
90-Day Mail Order Pharmacy
|
30-Day Supply Preferred Pharmacy or Mail Order Pharmacy
30-Day Supply Standard Pharmacy
90-Day Supply Preferred Pharmacy
90-Day Supply Standard Pharmacy
31 to 90-Day Mail Order Pharmacy
90-Day Mail Order Pharmacy
|
30-Day Supply Preferred Pharmacy or Mail Order Pharmacy
30-Day Supply Standard Pharmacy
90-Day Supply Preferred Pharmacy
90-Day Supply Standard Pharmacy
31 to 90-Day Mail Order Pharmacy
90-Day Mail Order Pharmacy
|
30-Day Supply Preferred Pharmacy or Mail Order Pharmacy
|
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|
30-Day Supply Standard Pharmacy
|
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90-Day Supply Preferred Pharmacy
|
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90-Day Supply Standard Pharmacy
|
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31 to 90-Day Mail Order Pharmacy
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90-Day Mail Order Pharmacy
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| 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%.
|
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| 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 |
In-network: Days 1-4 $295/day copayment |
| Outpatient Surgery Services |
In- and Out-of-network: $395 copayment |
In-network: $295 copayment |
| Primary Care Provider |
In-network: $10 copayment |
In-network: $5 copayment |
| Specialist |
In-network: $45 copayment |
In-network: $45 copayment |
| Preventive Care |
In-network: $0 copayment |
In-network: $0 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 |
In-network: $0 copayment |
| Lab and Clinical Diagnostic Tests |
In-network: $20 copayment |
In-network: $20 copayment |
| Outpatient X-rays |
In-network: $35 copayment |
In-network: $20 copayment |
| Ultrasound, EKGs, EEGs, Stress Test |
In-network: $40 copayment |
In-network: $35 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 |
In-network: $125 copayment |
| Medicare Covered Hearing Exams |
In-network: $15 copayment |
In-network: $10 copayment |
| Medicare Covered Dental |
In-network: $50 copayment |
In-network: $50 copayment |
| Supplemental Dental |
Not covered |
One exam and cleaning per year with Delta Dental Medicare Advantage Provider. |
| Medicare Covered Eye Exam |
In-network: $50 copayment |
In-network: $50 copayment |
| Supplemental Vision |
In-network: $10 copayment |
In-network: $10 copayment
|
| Inpatient Mental Health Care |
In-network: Days 1-3 $395 copayment/day Out-of-network: Days 1-4 $395 copayment/day |
In-network: Days 1-4 $295 copayment/day Out-of-network: Days 1-3 $395 copayment/day
|
| Outpatient Mental Health Care |
In-network: Individual or group therapy Out-of-network: $50 copayment |
In-network: Individual or group therapy Out-of-network: $50 copayment |
| Skilled Nursing Facility |
In- and Out-of-network: |
In- and Out-of-network: |
| 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) |
One Touch™ and Accu-Chek™ (All other brands are not covered) |
| 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
30-Day Supply Standard Pharmacy
90-Day Supply Preferred Pharmacy
90-Day Supply Standard Pharmacy
31 to 90-Day Mail Order Pharmacy
90-Day Mail Order Pharmacy
|
30-Day Supply Preferred Pharmacy or Mail Order Pharmacy
30-Day Supply Standard Pharmacy
90-Day Supply Preferred Pharmacy
90-Day Supply Standard Pharmacy
31 to 90-Day Mail Order Pharmacy
90-Day Mail Order Pharmacy
|
| 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. |
| Outpatient Surgery Services |
You pay nothing after you meet your deductible. Covered services include: |
| 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. |
| 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: |
| Supplemental Vision |
Not covered |
| Inpatient Mental Health Care |
You pay nothing after you meet your deductible. Covered services include: |
| Outpatient Mental Health Care |
You pay nothing after you meet your deductible. Covered services include: |
| Skilled Nursing Facility |
You pay nothing after you meet your deductible. |
| Physical Therapy |
You pay nothing after you meet your deductible. Covered services include: |
| 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. |
| 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 |
| 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. |
| 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 |
| Outpatient Mental Health Care |
Individual or group therapy $30 copayment |
| Skilled Nursing Facility |
Days 1-20 $0 copayment/day |
| 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): |
| Diabetes Monitoring Supplies and Test Strips1 |
One Touch™ and Accu-Chek™ |
| 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
30-Day Supply Standard Pharmacy
90-Day Supply Preferred Pharmacy
90-Day Supply Standard Pharmacy
31 to 90-Day Mail Order Pharmacy
90-Day Mail Order Pharmacy
|
| 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.
|
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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
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Outpatient Surgery Services |
Ambulatory surgical center: Outpatient hospital: |
Full coverage
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Primary Care Provider |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Specialist |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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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
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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. |
Full coverage
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Urgent Care |
Urgent Care Walk-In Clinic: |
Full coverage, including laboratory and radiology No copayment for preventive services, emergency services, anesthesia or clozapine management. |
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Low Cost Labs |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Lab and Clinical Diagnostic Tests |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Outpatient X-rays |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Ultrasound, EKGs, EEGs, Stress Test |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Radiation Therapy |
Therapeutic radiology services (such as radiation treatment for cancer): |
Full coverage |
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Diagnostic Radiology Services |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Medicare Covered Hearing Exams |
Exam to diagnose and treat hearing and balance issues: A hearing aid discount is offered with Simpli Hearing, LLC to NetworkCares members. Call Network Health for more information. |
Full coverage No copayment for hearing aid batteries |
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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): Our plan pays up to $3,000 every year for most dental services. |
Full coverage $.50 to $3 copayment per service
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Supplemental Dental |
Not covered |
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Medicare Covered |
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
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Supplemental Vision |
Not covered |
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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.
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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. |
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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
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Physical Therapy |
• In- and out-of-network: 0% - 20% of the cost |
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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. |
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Transportation |
Not covered |
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Medicare Part B Drugs |
• In- and out-of-network: 0% - 20% of the cost |
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Medicare Part D Drugs |
Covered |
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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
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Diabetes Monitoring Supplies |
• 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 |
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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 |
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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 |
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Durable Medical Equipment |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Prosthetic Devices |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Related Medical Supplies |
• In- and out-of-network: 0% - 20% of the cost |
Full coverage |
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Home Health Care |
• In- and out-of-network: $0 copayment |
Full coverage |
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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
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| Initial Drug Coverage |
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| Coverage gap | ||
| Catastrophic Coverage |
