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Medicare Plans

Plan Details

Network PlatinumPremier (PPO)

Ideal for those who prefer to pay a monthly premium and minimal copayments.




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  • Same costs for in- and out-of-network providers
  • Medical coverage with a $177 monthly premium and a low maximum out-of-pocket
  • Annual maximum out-of-pocket of $3,400
  • SilverSneakers® Fitness benefit
  • $0 medical deductible
  • $10 copayment for personal doctor (primary care provider) visits
  • $0 copayment for outpatient hospital services
  • $0 copayment for imaging services
  • $10 copayment for an annual routine vision exam
  • $0 copayment for an annual routine hearing exam
  • One dental cleaning and exam per year for $30
  • 100% coverage for preventive care
  • Travel coverage

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumPremier (PPO)

Monthly Premium
Annual Medical Deductible
Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

$3,400 Combined in- and out-of-network
Primary Care Provider Visit
Specialist Visit
Preventive Care*
Annual Medicare Wellness Visit
Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

Part B Vaccines

Hepatitis B, all other Part B vaccines

Inpatient Hospital Services1

Per admission

$75 per day, Days 1-5
$0 Days 6 and beyond
Outpatient Hospital Services
Diagnostic Tests

Such as ultrasound, EKG, stress test

Diagnostic Radiology Services– Advanced Imaging
Urgent Care Visit
Emergency Room Visit

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

Air and Ground Ambulance Services
Durable Medical Equipment

Such as insulin pumps1, CPAP machines, prosthetic devices1

Physician Telehealth Services
Virtual primary care and urgent care services cost the same as an in-person visit
Virtual Visit with MDLIVE®2

For medical (including dermatology) and mental health

Medicare Part B Drugs1
20% of the cost
Travel within the United States
Receive in-network coverage when you see a provider outside Wisconsin, anywhere in the United States
International Emergency Coverage

View the Evidence of Coverage at for details

$90 per incident
Maximum benefit
Pick Your Perks2

Reimbursement for the following extra benefits: dental services, vision hardware ($200 maximum), healthy home-delivered meals, non-emergency transportation, over-the-counter items, acupuncture, massage therapy, personal training (four visits or $225 maximum, whichever happens first), nutritional/dietary counseling

Not Included
Preventive Dental Services2
In-Network: 1 cleaning and exam per year for $30
Out-of-Network: $100 reimbursement
Medicare-Covered Dental Services

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

Optional Comprehensive Dental Coverage2
$39 monthly premium
Annual Maximum: $1,000
Annual Routine Vision Exam2
In-Network: $10
Out-of-Network: $40 reimbursement
Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

Over-the-Counter Coverage2
Not Included
Fitness with SilverSneakers®2
Routine Hearing Exam2
In-Network: $0
Out-of-Network: $40
Diagnostic Hearing Exam
Hearing Aids2

Maximum of two hearing aids per year
Hearing aid evaluation and fitting included

$679-$2,299 per device
Outpatient Mental Health

Individual or group therapy

Inpatient Mental Health1

Per admission

Opioid Treatment Services
Substance Abuse Services

Outpatient individual or group therapy

Skilled Nursing Facility1

Per admission
Once you reach your maximum out-of-pocket, you will pay $0 per day

Outpatient Physical1, Occupational1, Speech Therapy
Chiropractic Services

Manipulation of the spine to correct misalignment of one or more of the bones of your spine

Medicare-Covered Acupuncture

For chronic low back pain only, up to 12 visits in 90 days and no more than 20 visits per year

Medicare-Covered Home Health Care Visits1
20% of the cost
Radiation Therapy1

Up to 12 visits per year are covered for members who are undergoing chemotherapy and experiencing nausea

Home-Based Palliative Care
One palliative care evaluation and two follow up visits
Diabetes Monitoring Supplies and Test Strips

One Touch and Accu-Chek test strips, continuous glucose monitoring supplies limited to FreeStyle Libre® and Dexcom®. All other brands are not covered.

$0 for up to a 90-day supply
Diabetic Shoe Inserts

Copayment per pair

Non-Emergency Transportation

24 one-way trips to get to and from dialysis for members with end-stage renal disease (ESRD)

20% of the cost
*Includes abdominal aortic aneurysm screening, alcohol misuse screening and counseling, annual wellness visit, bone mass measurement, breast cancer screening, cardiovascular disease screening, cardiovascular disease risk reduction visit, cervical and vaginal cancer screening, colorectal cancer screening (screening colonoscopy, fecal occult blood test, flexible sigmoidoscopy), depression screening, diabetes screening, glaucoma screening, HIV screening, lung cancer screening, medical nutrition therapy services, Medicare Diabetes Prevention Program, obesity screening and therapy, prostate cancer screening, screening for sexually transmitted infections and counseling, smoking and tobacco use cessation counseling, one time Welcome to Medicare preventive visit
1Service may require prior authorization.

Network PlatinumPremier (PPO) Drug Plan Costs

Annual Drug Deductible
This plan does not include drug coverage
INITIAL COVERAGE Amount shown is the maximum you will pay, you may pay less.
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.

Network Health
1570 Midway Place
Menasha, WI 54952
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.