Network PlatinumPlus (PPO)

$89 per month

Medical coverage with a low maximum out-of-pocket

Same costs for in- and out-of-network providers
$0 medical deductible
$10 copayment for an annual eye exam
$15 copayment for primary care provider visits
$120 emergency room visit
$3,400 maximum out-of-pocket (combined in- and out-of-network)
100% coverage for preventive care
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 PlatinumPlus (PPO)
Premium	$89 per month
Deductible	This plan does not have a medical deductible.
Maximum Out-of-Pocket	$3,400 per year combined, in- and out-of-network
Inpatient Hospital Coverage¹	Days 1-5: $375/day copayment Days 6 and beyond: $0/day copayment
Outpatient Surgery Services¹	$350 copayment
Primary Care Provider	$15 copayment
Specialist	$40 copayment
Preventive Care	$0 copayment
Emergency Room	$120 copayment
Urgent Care	$25 copayment
Low Cost Labs	$0 copayment
Lab and Clinical Diagnostic Tests	$5 copayment
Outpatient X-rays	$25 copayment
Ultrasound, EKGs, EEGs, Stress Test	$25 copayment
Radiation Therapy	$60 copayment
Diagnostic Radiology Services (Such as MRIs, CT Scans)	$100 copayment
Medicare Covered Hearing Exams	$25 copayment
Medicare Covered Dental¹	$25 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	$25 copayment
Supplemental Vision	$10 copayment in-network, maximum $30 reimbursement out-of-network
Inpatient Mental Health Care	Days 1-10 $150 copayment/day Days 11-190 $0 copayment including “lifetime reserve days”
Outpatient Mental Health Care	Individual or group therapy $35 copayment
Skilled Nursing Facility¹	Days 1-20 $20 copayment/day Days 21-54 $172 copayment/day Days 55-100 $0 copayment
Physical Therapy	$40 copayment
Ambulance	$250 copayment
Transportation	Not covered
Medicare Part B Drugs and Chemotherapy	20%
Medicare Part D Drugs	Not 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.

Medicare Plans

Network PlatinumPlus (PPO)