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Network PlatinumSelect (PPO)
$0 per month
Medical and pharmacy coverage with zero premium and low copayments
- Same costs for in- and out-of-network providers
- $0 medical deductible
- $0 copayment for 90-day mail order Tier 1 drugs
- $10 copayment for an annual eye exam
- $15 copayment for primary care provider visits
- $90 emergency room visit
- $5,900 maximum out-of-pocket (combined in- and out-of-network)
- 100% coverage for preventive care
- Prescription drug coverage
- Travel coverage
- Hearing aid discount benefit
Services with a 1 may require prior authorization.
|
Northeast Medicare Advantage |
Network PlatinumSelect (PPO) |
| Premium | $0 per month (includes pharmacy) |
| Deductible | This plan does not have a medical deductible. |
|
Maximum Out-of-Pocket |
$5,900 per year combined, in- and out-of-network |
|
Inpatient Hospital Coverage1 |
Days 1-4: $450/day copayment |
|
Outpatient Surgery Services1 |
$395 copayment |
|
Primary Care Provider |
$15 copayment |
|
Specialist |
$50 copayment |
|
Preventive Care |
$0 copayment |
|
Emergency Room |
$90 copayment |
|
Urgent Care |
$50 copayment |
|
Low Cost Labs |
$0 copayment |
|
Lab and Clinical Diagnostic Tests |
$20 copayment |
|
Outpatient X-rays |
$30 copayment |
|
Ultrasound, EKGs, EEGs, Stress Test |
$40 copayment |
|
Radiation Therapy |
20% |
|
Diagnostic Radiology Services |
$150 copayment |
|
Medicare Covered Hearing Exams |
$15 copayment |
|
Medicare Covered Dental1 |
$50 copayment (does not include services in connection with care, treatment, filling, removal or replacement of teeth) |
|
Supplemental Dental |
Not covered |
|
Medicare Covered Eye Exam |
$50 copayment |
|
Supplemental Vision |
$10 copayment in-network, maximum $30 reimbursement out-of-network |
|
Inpatient Mental Health Care |
Days 1-4 $395 copayment/day |
|
Outpatient Mental Health Care |
Individual or group therapy $40 copayment
|
|
Skilled Nursing Facility1 |
Days 1-20 $0 copayment/day |
|
Physical Therapy |
$40 copayment |
|
Ambulance |
$300 copayment |
|
Transportation |
Not covered |
|
Medicare Part B Drugs |
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 |
One Touch™ and Accu-Chek™ (All other brands are not covered) $0 copayment, applies up to a |
|
Diabetes Self-Monitoring Training1 |
$0 copayment |
|
Theraputic Shoes/Inserts1 |
$10 copayment |
|
Prosthetic Devices1 |
20% of the cost |
|
Related Medical Supplies1 |
20% of the cost |
|
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 PlatinumSelect (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 |
$395 for tiers 3, 4 and 5 only |
| Initial Coverage |
30-Day Supply Preferred 30-Day Supply Standard Pharmacy 90-Day Supply Preferred Pharmacy 90-Day Supply Standard Pharmacy 31 to 90-Day Mail Order Pharmacy 90-Day Mail Order Pharmacy |
| 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. |
