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Plan Details

Network Health Medicare Anywhere (PPO)

Ideal for those who prefer a monthly premium and lower copayments.

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Premium

$29 per month

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  • $29 monthly premium
  • $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
  • Annual dental exam and cleaning
  • Hearing Aid discount benefit
  • Freedom to see in- and out-of-network providers

Southeast Medicare Advantage PPO Plan Benefits

Network Health Medicare Anywhere (PPO)

Services with a 1 may require prior authorization.
Monthly Premium
$29
Annual Medical Deductible
$0
Annual Maximum Out-of-Pocket

Combined in- and out-of-network

$4,900

Inpatient Hospital Coverage 1

Per admission

In-network: $295 per day, Days 1-5 $0 Days 6 and beyond
Out-of-network: $495 per day, Days 1-5 $0 Days 6 and beyond
Outpatient Surgery Services

including Ambulatory Surgical Center Services such as colonoscopies.

In-network: $285
Out-of-network: $395
Primary Care Provider
In-network: $7
Out-of-network: $15
Specialist
In-network: $45 copayment
Out-of-network: $65 copayment
Preventive Care
In-network: $0
Out-of-network: $15
Emergency Room

Copayment is waived if admitted to a U.S. hospital within 24 hours.

In- and Out-of-network: $90 copayment
Urgent Care
In- and Out-of-Network: $45
Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization 1
In-network: $0-$20
Out-of-network: $25
X-rays
In-network: $20
Out-of-network: $45
Ultrasound, EKGs, EEGs, Stress Test
In-network: $35
Out-of-network: $45
Radiation Therapy 1

Per service

In-network: 20%
Out-of-network: 25%
Diagnostic Radiology Services 1

Such as MRIs, CT Scans

In-network: $125
Out-of-network: $140
Medicare Covered Hearing Exams

Diagnostic

In-network: $10
Out-of-network: $25
Medicare Covered Dental Exam

Does not include services in connection with care, treatment, filling, removal or replacement teeth.

In-network: $50
Out-of-network: $55
Optional Dental Benefit with Delta Dental Medicare Advantage
In-network: $37 monthly premium
Annual Maximum: $1,000
Medicare Covered Eye Exam
In-network: $50
Out-of-network: $55
Inpatient Mental Health 1
In-network: $295 per day, Days 1-4 $0 days 5 and beyond
Out-of-network: $395 per day, Days 1-3 $0 days 4 and beyond
Outpatient Individual or Group Therapy, Psychiatric, Telehealth
In-network: $40
Out-of-network: $50
Skilled Nursing Facility 1
In- and Out-of-network: $0 per day Days 1-20 $178 per day, Days 21-49
Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

In-network: $40
Out-of-network: $75
Ambulance
In- and Out-of-network: $250 copayment
Transportation
Not covered
Medicare Part B Drugs and Chemotherapy
In-network: 20% of the cost
Out-of-network: 50% of the cost
Medicare Part D Drugs
In-network: Covered
Out-of-network: Not covered
Chiropractic Care

Manipulation of the spine to correct when one or more of the bones in your spine move out of position.

In-network: $20
Out-of-network: $40
Diabetes Monitoring Supplies and Test Strips 1

One Touch™ and Accu-Chek™ All other brands are not covered

In-network: $0 for up to a 90-day supply
Out-of-network: $0 for up to a 90-day supply
Diabetes Self-Monitoring Training 1
In- and Out-of-network: $0 copayment
Diabetic Shoes/Inserts
In- and Out-of-network: $10
Durable Medical Equipment Such as Insulin Pumps 1 CPAP machines, Prosthetic Devices 1
In-network: 20% of the cost
Out-of-network: 25% of the cost
Medicare Covered Home Health Care Visits 1
In-network: $0
Out-of-network: $15
MDLIVE ® Virtual Doctor Visits
$0
Hearing Aid Discount
Includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Maximum of two hearing aids per year. 
Select hearing aids discounted to
$1,220-$1,985 per device.
Save $775–$1,215 per hearing aid.
Non-Medicare Covered
Eyewear Discounts offered at EyeMed providers. 
Discounts Included
SilverSneakers ® Fitness
Included
Caregiver Support
Included
Over-the-Counter Coverage
Not included

Network Health Medicare Anywhere (PPO) Drug Plan Costs

When your coverage starts, you pay a deductible for tiers 4 and 5 only; and copayments until total drug costs (what you and Network Health pay) reach $4,020.
Drug Deductible
$0 for Tiers 1, 2 and 3
$250 For Tiers 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
28% for Tier 5

30-Day Supply Standard Pharmacy
$4 for Tier 1       $47 for Tier 3
$14 for Tier 2     $91 for Tier 4
28% 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 $4,020. You pay 25% and Network Health pays 75% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.
Catastrophic Coverage
You enter catastrophic coverage when your true out-of-pocket costs reach $6,350. You pay the greater of $3.60 or 5% of the cost for generic drugs and $8.95 or 5% of the cost for brand name drugs.

This information is not a complete description of benefits. Call 800-378-5234 (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
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.

Copyright 2022 Network Health Plan, Network Health Insurance Corporation and Network Health Administrative Services, LLC. All rights reserved. HMO and POS plans underwritten by Network Health Plan. Self-insured plans administered by Network Health Administrative Services, LLC. Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. NetworkCares is a PPO D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. Y0108_1850-03-0921_2022_F Last Updated Feb 28, 2022 2:33 PM

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