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Medicare Plans

Plan Details

Network Health Medicare Go (PPO)

Ideal for those who prefer no monthly premium and low copayments.



$0 per month

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  • $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

Southeast Medicare Advantage PPO Plan Benefits

Network Health Medicare Go (PPO)

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

Combined in- and out-of-network

Inpatient Hospital Coverage1

Per admission.

In-network: $395 per day, Days 1-4 $0 Days 5 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: $385
Out-of-network: $415
Primary Care Provider
In-network: $10
Out-of-network: $20
In-network: $45
Out-of-network: $75
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
Urgent Care
In- and Out-of-Network: $45
Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization1
In-network: $0-$20
Out-of-network: $30
In-network: $35 copayment
Out-of-network: $45 copayment
Ultrasound, EKGs, EEGs, Stress Test
In-network: $40
Out-of-network: $50
Radiation Therapy1

Per service

In-network: 20% of the cost
Out-of-network: 25% of the cost
Diagnostic Radiology Services1

Such as MRIs, CT Scans

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


In-network: $15
Out-of-network: $25
Medicare Covered Dental Exam

Does not include services in connection with care, treatment, filling, removal or replacement of 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 Health1
In- and Out-of-network: $395 per day, Days 1-4 $0 Days 5 and beyond
Outpatient Individual or Group Therapy, Psychiatric, Telehealth
In-network: $40
Out-of-network: $50
Skilled Nursing Facility1
In- and Out-of-network: $0 Days 1-20 $178 per day, Days 21-57
Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

In-network: $40
Out-of-network: $75
In- and Out-of-network: $275 copayment
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 Strips1

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 Training1
In- and Out-of-network: $0 copayment
Diabetic Shoes/Inserts
In- and Out-of-network: $10 copayment
Durable Medical Equipment Such as Insulin Pumps1 CPAP machines, Prosthetic Devices1
In-network: 20% of the cost Out-of-network: 25% of the cost
Medicare Covered Home Health Care Visits1
In-network: $0
Out-of-network: $15
MDLIVE® Virtual Doctor Visits
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
Caregiver Support
Over-the-Counter Coverage
Not included

Network Health Medicare Go (PPO) Drug 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, $275 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
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 $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%a 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
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.