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Medicare Plans

Network PlatinumSelect (PPO)

$0 per month

Medical and pharmacy coverage with zero premium and low copayments

  • 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 an annual eye exam
  • $15 copayment for primary care provider visits
  • $90 emergency room visit
  • $5,900 maximum out-of-pocket (combined in- and out-of-network)
  • 100% coverage for preventive care
  • Prescription drug coverage
  • Travel coverage
  • Hearing aid discount benefit

Services with a 1 may require prior authorization.

Northeast Medicare Advantage
PPO
Plan Benefits

 Network PlatinumSelect (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

Days 1-4: $450/day copayment
Days 5 and beyond: $0/day copayment

Outpatient Surgery Services1

$395 copayment

Primary Care Provider

$15 copayment

Specialist

$50 copayment

Preventive Care

$0 copayment

Emergency Room

$90 copayment

Urgent Care

$50 copayment

Low Cost Labs

$0 copayment

Lab and Clinical Diagnostic Tests

$20 copayment

Outpatient X-rays

$30 copayment

Ultrasound, EKGs, EEGs, Stress Test

$40 copayment

Radiation Therapy

20%

Diagnostic Radiology Services
(Such as MRIs, CT Scans)

$150 copayment

Medicare Covered Hearing Exams

$15 copayment

Medicare Covered Dental1

$50 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

Supplemental Dental

Not covered

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 $395 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 21-57 $172 copayment/day
Days 58-100 $0 copayment

Physical Therapy

$40 copayment

Ambulance

$300 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  PlatinumSelect (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

$395 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
25% for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1     $47 for Tier 3
$14 for Tier 2   $91 for Tier 4
25% 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.


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.