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 Coverage1 |
Days 1-6 $295/day copayment Days 7 and beyond $0 copayment |
Outpatient Surgery Services1 |
$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 Dental1 |
$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 |
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 $40 copayment |
Skilled Nursing Facility1 |
Days 1-20 $0 copayment/day Days 21-49 $172 copayment/day Days 50-100 $0 copayment Prior 3 day inpatient hospital stay not required |
Physical Therapy |
$30 copayment |
Ambulance |
$225 copayment |
Transportation |
Not covered |
Medicare Part B Drugs and Chemotherapy |
20% |
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 Training1 |
$0 copayment |
Theraputic Shoes/Inserts1 |
$10 copayment |
Prosthetic Devices1 |
20% of the cost |
Related Medical Supplies1 |
20% of the cost |
Home Health Care1 |
$0 copayment |