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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.

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

Annual Maximum
Out-of-Pocket
Combined in- and
out-of-network

$4,900 

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 

Specialist

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
Diagnostic
Tests Genetic/
molecular testing requires
authorization1

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 Therapy1
Per service

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

Diagnostic Radiology
Services1
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
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
Visit networkhealth.com/
medicare/additional-
benefits.


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 

Inpatient
Mental
Health1

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 Facility1
Per admission.

In- and Out-of-network:
$0 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 

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 Strips1
One Touch™ and
Accu-Check™

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 

Diabetic
Shoes/Inserts
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%.

 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.


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.