Network PlatinumPremier (PPO)
$195 per month
Medical coverage for people who want fewer copayments
- Same costs for in- and out-of-network providers
- $0 medical deductible
- $10 copayment for primary care provider visits
- $10 copayment for an annual eye exam
- $75 for hospital stays days 1-5 and $0 for additional days
- $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 |
Network PlatinumPremier (PPO) |
Premium | $195 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: $75/day copayment |
Outpatient Surgery Services1 |
$0 copayment |
Primary Care Provider |
$10 copayment |
Specialist |
$20 copayment |
Preventive Care |
$0 copayment |
Emergency Room |
$120 copayment |
Urgent Care |
$0 copayment |
Low Cost Labs |
$0 copayment |
Lab and Clinical Diagnostic Tests |
$0 copayment |
Outpatient X-rays |
$0 copayment |
Ultrasound, EKGs, EEGs, |
$0 copayment |
Radiation Therapy |
$0 copayment |
Diagnostic Radiology Services |
$0 copayment |
Medicare Covered Hearing Exams |
$0 copayment |
Medicare Covered Dental1 |
$0 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 |
$0 copayment |
Supplemental Vision |
$10 copayment in-network, maximum $30 reimbursement out-of-network |
Inpatient Mental Health Care |
Days 1-190 $0 copayment/day including “lifetime reserve days” |
Outpatient Mental Health Care |
Individual or group therapy $0 copayment |
Skilled Nursing Facility1 |
Days 1-100 $0 copayment/day |
Physical Therapy |
$20 copayment |
Ambulance |
$0 copayment |
Transportation |
Not covered |
Medicare Part B Drugs |
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 |
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 |
$0 copayment |
Related Medical Supplies1 |
$0 copayment |
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.