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Medicare Plans

Network Health Medicare Anywhere (PPO)

$29 per month

Medical and pharmacy coverage with a low monthly premium and low copayments

  • $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

Services with a 1 may require prior authorization.

Medicare Advantage
PPO Plan Benefits
Network Health Medicare
Anywhere (PPO)
Monthly Premium $29 
Annual  Medical Deductible $0

Annual Maximum
Combined in- and


Inpatient Hospital1
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 


In-network: $45 
Out-of-network: $65 

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
Tests Genetic/
molecular testing requires

In-network: $0-$20 
Out-of-network: $25 


In-network: $20 
Out-of-network: $45 

Ultrasound, EKGs, EEGs, Stress Test

In-network: $35 
Out-of-network: $45 

Radiation Therapy1
Per service

In-network: 20%
Out-of-network: 25%

Diagnostic Radiology
Such as MRIs,
CT Scans

In-network: $125 
Out-of-network: $140 

Medicare Covered

In-network: $10 
Out-of-network: $25 

Medicare Covered
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

In-network: $37 monthly premium
Annual Maximum: $1,000
Out-of-network: $37 monthly premium
Annual Maximum: $1,000

Medicare Covered
Eye Exam

In-network: $50 
Out-of-network: $55 


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,

In-network: $40
Out-of-network: $50 

Skilled Nursing Facility1
Per admission.

In- and Out-of-network:
$0 Days 1-20 $178 per day, days 21-49

Physical, Occupational,
Includes comprehensive
outpatient rehabilitation

In-network: $40 
Out-of-network: $75 


In- and Out-of-network: $250 


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

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



In- and Out-of-network: $0 

Copayment per pair

In- and Out-of-network: $10 

Durable Medical Equipment1
Such as Insulin Pumps,
CPAP machines and
Prosthetic Devices

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 


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. 


 Nnetwork Health Medicare Anywhere (PPO) Drug Costs

When your coverage starts, you have a $0 deductible for Tiers 1-3

 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%.


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.

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.