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Plan Details

Network PlatinumPlus Pharmacy (PPO)

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

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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
$0
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
$0
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
$0
MDLIVE® Virtual Doctor Visits
$0
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.


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.

Copyright 2022 Network Health Plan, Network Health Insurance Corporation and Network Health Administrative Services, LLC. All rights reserved. HMO and POS plans underwritten by Network Health Plan. Self-insured plans administered by Network Health Administrative Services, LLC. Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. NetworkCares is a PPO D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. Y0108_1850-03-0921_2022_F Last Updated Feb 28, 2022 2:33 PM

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