Medicare Plans

Plan Details

NetworkPrime (MSA)

Ideal for those who prefer no monthly premium and want to control their health care costs.

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Premium

$0 per month

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  • No monthly premium
  • $1,500 deposited by Medicare in your Medicare Medical Savings Account
  • $5,100 medical deductible
  • You pay nothing for Medicare-covered services after you meet your deductible

NetworkPrime (MSA) Benefits

NetworkPrime (MSA)

Services with a 1 may require prior authorization.
Monthly Premium
$0
Annual Medical Deductible
$5,100 per year
Annual Maximum Out-of-Pocket

Combined in-and out-of-network

$5,100
Inpatient Hospital Coverage1

Per admission

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Outpatient Surgery Services

including Ambulatory Surgical Center Services such as colonoscopies.

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Primary Care Provider
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Specialist
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Preventive Care
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Emergency Room

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

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Urgent Care
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Lab and Clinical Diagnostic Tests Genetic/molecular testing requires authorization1
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
X-rays
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Ultrasound, EKGs, EEGs, Stress Test
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Radiation Therapy1

Per service

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diagnostic Radiology Services1

Such as MRIs, CT Scans

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Medicare Covered Hearing Exams

Diagnostic

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Medicare Covered Dental Exam

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

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.

Optional Dental Benefit with Delta Dental Medicare Advantage

$37 monthly premium Annual Maximum: $1,000

Medicare Covered Eye Exam
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Inpatient Mental Health1

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.

Outpatient Individual or Group Therapy, Psychiatric, Telehealth

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.

Skilled Nursing Facility1

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.

Physical, Occupational, Speech Therapy

Includes comprehensive outpatient rehabilitation facility.

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.

Ambulance
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Transportation
Not covered
Medicare Part B Drugs and Chemotherapy

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.

Medicare Part D Drugs
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Chiropractic Care

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

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.

Diabetes Monitoring Supplies and Test Strips1

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

Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diabetes Self-Monitoring Training1
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Diabetic Shoes/Inserts
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Durable Medical Equipment Such as Insulin Pumps1 CPAP machines, Prosthetic Devices1
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
Medicare Covered Home Health Care Visits1
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
MDLIVE® Virtual Doctor Visits
Until you meet your annual deductible of $5,100, you pay up to 100% of the Medicare approved amount. After you meet your annual deductible you pay $0 for Medicare covered services. No prior authorization required.
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
Not included
Caregiver Support
Included
Over-the-Counter Coverage
Not included

NetworkPrime (MSA) Drug 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 800-378-5237 (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 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.