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Medicare Plans

Network Health Medicare Anywhere (PPO)

$25 per month

Medical and pharmacy coverage with a low monthly premium and low copayments

  • $25 monthly premium
  • $0 medical deductible
  • $0 copayment for 90-day mail order Tier 1 drugs
  • $5 copayment for primary care provider visits
  • $10 copayment for an annual eye exam
  • $90 emergency room visit
  • 100% coverage for preventive care
  • Prescription drug coverage
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Annual dental exam and cleaning
  • Hearing aid discount benefit
  • Freedom to see in- and out-of-network providers

Services with a 1 may require prior authorization.

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


$4,500 per year combined,
in- and out-of-network

Inpatient Hospital

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

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

Primary Care Provider

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


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

Preventive Care

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

Emergency Room

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

Urgent Care

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

Low Cost Labs

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

Lab and Clinical

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

Outpatient X-rays

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

Ultrasound, EKGs, EEGs, Stress Test

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

Radiation Therapy

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

Diagnostic Radiology
Services (Such as MRIs,
CT Scans)

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

Medicare Covered

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

Medicare Covered

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

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

Supplemental Vision

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

Health Care

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”

Health Care

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

Physical Therapy

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


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


Not covered

Medicare Part B Drugs
and Chemotherapy

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

Medicare Part D Drugs


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

Diabetes Monitoring
and Test Strips1

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

$0 copayment, applies up to a 90-day supply


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


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

Prosthetic Devices1

In-network: 20% of the cost
Out-of-network: 25%

Related Medical

In-network: 20% of the cost
Out-of-network: 25%

Home Health Care1

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


This information is not a complete description of benefits. Call 800-378-5237 (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 Medicare Anywhere (PPO) Drug Costs

When your coverage starts, you pay a deductible for tiers 3, 4 and 5 only; and copayments until total drug costs (what you and Network Health pay) reach $3,820.

 Drug Deductible

 $250 For tiers 3, 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
28% for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1      $47 for Tier 3
$14 for Tier 2    $91 for Tier 4
28% 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 $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 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
1570 Midway Place
Menasha, WI 54952
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.