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Medicare Plans

Network PlatinumPremier Pharmacy (PPO)

$295 per month

Medical and pharmacy coverage for people who want few copayments

  • Same costs for in- and out-of-network providers
  • $0 medical deductible
  • $0 copayment for 90-day mail order Tier 1 drugs
  • $10 for primary care provider visits
  • $10 copayment for an annual eye exam
  • $75 for hospital stays days 1-5 and $0 for additional days
  • $3,400 maximum out-of-pocket (combined in- and out-of-network)
  • 100% coverage for preventive care
  • Prescription drug coverage
  • Travel coverage
  • SilverSneakers® Fitness benefit
  • Hearing aid discount benefit
  • Annual dental exam and cleaning

Services with a 1 may require prior authorization.

Northeast Medicare Advantage
PPO
Plan Benefits

 Network PlatinumPremier Pharmacy (PPO)
Premium $295 per month (includes pharmacy)
Deductible This plan does not have a medical deductible.

Maximum Out-of-Pocket

$3,400 per year combined, in- and out-of-network

Inpatient Hospital Coverage1

Days 1-5: $75/day copayment

Days 6 and beyond: $0/day copayment

Outpatient Surgery Services1

$0 copayment

Primary Care Provider

$10 copayment

Specialist

$20 copayment

Preventive Care

$0 copayment

Emergency Room

$120 copayment 

Urgent Care

$0 copayment

Low Cost Labs

$0 copayment

Lab and Clinical Diagnostic Tests

$0 copayment

Outpatient X-rays

$0 copayment

Ultrasound, EKGs, EEGs, Stress Test

$0 copayment

Radiation Therapy

$0 copayment

Diagnostic Radiology Services
(Such as MRIs, CT Scans)

$0 copayment

Medicare Covered Hearing Exams

$0 copayment

Medicare Covered Dental1

$0 copayment

(does not include services in connection with care, treatment, filling, removal or replacement of teeth)

Supplemental Dental

One exam and cleaning per year with Delta Dental Medicare Advantage Provider. $30 copayment, no coverage out-of-network.

Medicare Covered Eye Exam

$0 copayment

Supplemental Vision

$10 copayment in-network, maximum $30 reimbursement out-of-network

Inpatient Mental Health Care

Days 1-190 $0 copayment/day including “lifetime reserve days”

Outpatient Mental Health Care

Individual or group therapy

$0 copayment

Skilled Nursing Facility1

Days 1-100 $0 copayment/day

Physical Therapy

$20 copayment

Ambulance

$0 copayment

Transportation

Not covered

Medicare Part B Drugs
and Chemotherapy

20%

Medicare Part D Drugs

Covered

Chiropractic Care

$20 copayment for manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position).

Diabetes Monitoring Supplies
and Test Strips1

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

$0 copayment, applies up to a 90-day supply

Diabetes Self-Monitoring Training1

$0 copayment

Theraputic Shoes/Inserts1

$10 copayment 

Prosthetic Devices1

$0 copayment  

Related Medical Supplies1

$0 copayment  

Home Health Care1

$0 copayment 

 

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. 

 

 Network PlatinumPremier Pharmacy (PPO) Drug Plan Costs

When your coverage starts, you pay a deductible for tiers 3, 4 and 5 only; and copayments until total drug costs (what you and Network Health pay) reach $3,820.

Drug Deductible

$260 for tiers 3, 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 $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.

 Catastrophic Coverage

You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.


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.