Plan Details

Network PlatinumPlus Pharmacy (PPO)

Ideal for those who prefer low limit on costs and affordable premiums.

Premium

$123 per month

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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
$10 copayment for primary care provider visits
$120 emergency room visit
$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

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPlus Pharmacy (PPO)

Services with a ¹ may require prior authorization.

Monthly Premium

$123 per month (includes pharmacy)

Annual Medical Deductible

This plan does not have a medical deductible.

Annual Maximum Out-of-Pocket

Combined in-and out-of-network

$3,400

Inpatient Hospital Coverage¹

Per admission

$175 per day, Days 1-5 $0 Days 6 and beyond

Outpatient Surgery Services

including Ambulatory Surgical Center Services such as colonoscopies.

$350

Primary Care Provider

$15

Specialist

$40

Preventive Care

Emergency Room

Copayment is waived if admitted to a U.S. hospital within 24 hours.

$120

Urgent Care

$25

Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization¹

$0-$5

X-rays

$25

Ultrasound, EKGs, EEGs, Stress Test

$25

Radiation Therapy¹

Per service

$60

Diagnostic Radiology Services¹

Such as MRIs, CT Scans

$100

Medicare Covered Hearing Exams

Diagnostic

$25

Medicare Covered Dental Exam

Does not include services in connection with care, treatment, filling, removal or replacement teeth.

$25

Optional Dental Benefit with Delta Dental Medicare Advantage

$37 monthly premium Annual Maximum: $1,000

Medicare Covered Eye Exam

$25

Inpatient Mental Health¹

$150 per day, Days 1-10 $0 Days 11 and beyond

Outpatient Individual or Group Therapy, Psychiatric, Telehealth

$35

Skilled Nursing Facility¹

$20 per day, Days 1-20 $178 per day, Days 21-54

Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

$40

Ambulance

$250

Transportation

Not covered

Medicare Part B Drugs and Chemotherapy

20% of the cost

Medicare Part D Drugs

Covered

Chiropractic Care

Manipulation of the spine to correct when one or more of the bones in your spine move out of position.

$20

Diabetes Monitoring Supplies and Test Strips¹

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

$0 for up to a 90-day supply

Diabetes Self-Monitoring Training¹

Diabetic Shoes/Inserts

$10

Durable Medical Equipment Such as Insulin Pumps¹ CPAP machines, Prosthetic Devices¹

20% of the cost

Medicare Covered Home Health Care Visits¹

MDLIVE^® Virtual Doctor Visits

Hearing Aid Discount

Includes a one-year warranty, three office visits, one pack of batteries and one year of loss and damage insurance. Maximum of two hearing aids per year.

Select hearing aids discounted to
$1,220-$1,985 per device.
Save $775–$1,215 per hearing aid.

Non-Medicare Covered
Eyewear Discounts offered at EyeMed providers.

Discounts included

SilverSneakers^® Fitness

Included

Caregiver Support

Included

Over-the-Counter Coverage

$50 per quarter

Network PlatinumPlus Pharmacy (PPO) Drug Plan Costs

Your coverage starts, when you have a $0 deductible for Tiers 1-3

Drug Deductible

$260 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% of the cost 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% of the cost 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.

This information is not a complete description of benefits. Call 800-378-5234 (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.

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Medicare Plans

Plan Details

Network PlatinumPlus Pharmacy (PPO)

Premium

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPlus Pharmacy (PPO)

Network PlatinumPlus Pharmacy (PPO) Drug Plan Costs