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Medicare Plans

Network Health Medicare Go (PPO) 

$0 per month

Medical and pharmacy coverage with zero premium and low copayments

  • $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
  • 100% coverage for preventive care
  • Prescription drug coverage
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Hearing aid discount benefit
  • Freedom to see in- and out-of-network providers

Services with a 1 may require prior authorization.

 Southeast Medicare Advantage
Plan Benefits
 Network Health Medicare Go (PPO)
Premium $0 per month (includes pharmacy)
Deductible This plan does not have a medical deductible.

Maximum Out-of-Pocket

$5,900 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

Outpatient Surgery Services1

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

Primary Care Provider

In-network: $10 copayment
Out-of-network: $20 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: $30 copayment

Lab and Clinical Diagnostic Tests

In-network: $20 copayment
Out-of-network: $30 copayment

Outpatient X-rays

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

Ultrasound, EKGs, EEGs, Stress Test

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

Radiation Therapy

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

Diagnostic Radiology Services
as MRIs, CT Scans)

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

Medicare Covered Hearing Exams

In-network: $15 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)

Supplemental Dental

Not covered

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

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”

Outpatient Mental 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 21-57 $172 copayment/day
Days 58-100 $0 copayment

Physical Therapy

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


In- and Out-of-network: $275 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 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

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

Theraputic Shoes/Inserts1

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

Prosthetic Devices1

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

Related Medical Supplies1

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 Go (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

 $275 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
27% for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1      $47 for Tier 3
$14 for Tier 2    $91 for Tier 4
27% 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.