Plan Details

Network PlatinumPremier (PPO)

Ideal for those who prefer travel coverage.

Premium

$195 per month

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$0 medical deductible
$10 copayment 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
Travel coverage
SilverSneakers® Fitness benefit
Hearing aid discount benefit
Annual dental exam and cleaning

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPremier (PPO)

Services with a ¹ may require prior authorization.

Monthly Premium

$195

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

$75 per day, Days 1-5 $0 Days 6 and beyond

Outpatient Surgery Services

including Ambulatory Surgical Center Services such as colonoscopies.

Primary Care Provider

$10

Specialist

$20

Preventive Care

Emergency Room

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

$120

Urgent Care

Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization¹

X-rays

Ultrasound, EKGs, EEGs, Stress Test

Radiation Therapy¹

Per service

Diagnostic Radiology Services¹

Such as MRIs, CT Scans

Medicare Covered Hearing Exams

Diagnostic

Medicare Covered Dental Exam

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

Optional Dental Benefit with Delta Dental Medicare Advantage

$37 monthly premium Annual Maximum: $1,000

Medicare Covered Eye Exam

Inpatient Mental Health¹

$0 Days 1-90 $0 Days 91 and beyond

Outpatient Individual or Group Therapy, Psychiatric, Telehealth

Skilled Nursing Facility¹

Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

$20

Ambulance

Transportation

Not covered

Medicare Part B Drugs and Chemotherapy

20% of the cost

Medicare Part D Drugs

Not 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

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

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

Not included

Network PlatinumPremier (PPO) Drug Plan Costs

Drug Deductible

This plan does not include drug coverage

Initial Coverage

This plan does not include drug coverage

Coverage Gap

This plan does not include drug coverage

Catastrophic Coverage

This plan does not include drug coverage

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 PlatinumPremier (PPO)

Premium

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPremier (PPO)

Network PlatinumPremier (PPO) Drug Plan Costs