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 PPO 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
Specialist	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 (Such 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
Ambulance	In- and Out-of-network: $275 copayment
Transportation	Not covered
Medicare Part B Drugs and Chemotherapy	In-network: 20% Out-of-network: 25%
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): 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%.
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 Health Medicare Go (PPO)