For information on the coronavirus vaccine and your benefits as a Network Health member, click here.

Network Health Logo

Medicare Plans

Network Health Medicare Go (PPO) 

$0 per month

Medical and pharmacy coverage with zero premium and low copayments

  • $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

Services with a 1 may require prior authorization.

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

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

$5,900 

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 1-4 $0 Days 5 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 

Specialist

In-network: $45 
Out-of-network: $75 

Medicare Covered
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: $35 
Out-of-network: $45 

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
Diagnostic

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
Visit networkhealth.com/medicare/
plan-materials for details.

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: $395 per day, Days 1-4 $0 Days 5 and beyond
Out-of-network: $395 per day, Days 1-4 $0 Days 5 and beyond

Outpatient Mental Health
Individual or Group Therapy,
Psychiatric, Telehealth

In-network: $40 
Out-of-network: $50 

Skilled Nursing Facility1
Per mission

In-network: $0 Days 1-20 $178 per day, Days 21-57
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 

Ambulance

In- and Out-of-network: $275 

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
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

In- and Out-of-network: $0 

Diabetic Shoe Inserts
Copayment per pair

In- and Out-of-network: $10 

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: 

 

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 Go (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, $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.


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.