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Medicare Plans

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 Coverage1

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 Services1

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 Dental1

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 Facility1

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 Training1

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

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

Theraputic Shoes/Inserts1

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

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

Prosthetic Devices1

In-network: 20% of the cost

Out-of-network: 25%

In-network: 20% of the cost

Out-of-network: 25%

Related Medical Supplies1

In-network: 20% of the cost

Out-of-network: 25%

In-network: 20% of the cost

Out-of-network: 25%

Home Health Care1

In-network: $0 copayment

Out-of-network: $15 copayment

In-network: $0 copayment

Out-of-network: $15 copayment


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.