Network PlatinumChoice (PPO)

$25 per month

Medical and pharmacy coverage with low monthly premium

Same costs for in- and out-of-network providers
$0 medical deductible
$0 copayment for 90-day mail order Tier 1 drugs
$10 copayment for primary care provider visits
$10 copayment for an annual eye exam
$90 emergency room visit
$4,500 maximum out-of-pocket (combined in- and out-of-network)
100% coverage for preventive care
Prescription drug coverage
Travel coverage
SilverSneakers® Fitness benefit
Hearing Aid discount benefit
Annual dental exam and cleaning

Services with a ¹ may require prior authorization.

Northeast Medicare Advantage PPO Plan Benefits	Network PlatinumChoice (PPO)
Premium	$25 per month (includes pharmacy)
Deductible	This plan does not have a medical deductible.
Maximum Out-of-Pocket	$4,500 per year combined, in- and out-of-network
Inpatient Hospital Coverage¹	Days 1-4: $425/day copayment Days 5 and beyond: $0/day copayment
Outpatient Surgery Services¹	$395 copayment
Primary Care Provider	$10 copayment
Specialist	$50 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	$30 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, no coverage out-of-network.
Medicare Covered Eye Exam	$50 copayment
Supplemental Vision	$10 copayment in-network, maximum $30 reimbursement out-of-network
Inpatient Mental Health Care	Days 1-4 $295 copayment/day Days 5-190 $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
Physical Therapy	$40 copayment
Ambulance	$275 copayment
Transportation	Not covered
Medicare Part B Drugs and Chemotherapy	20%
Medicare Part D Drugs	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).
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

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 PlatinumChoice (PPO) Drug Plan 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	$260 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%.
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.

Medicare Plans

Network PlatinumChoice (PPO)