Plan Details

Network PlatinumSelect (PPO)

Ideal for those who prefer to pay for services with low copayments and not have a monthly premium.

Premium

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$550 Pick Your Perks flexible benefits program available, covering dental, vision, over-the-counter items, acupuncture, massage therapy and more
Same costs for in- and out-of-network providers
Prescription drug coverage
Annual maximum out-of-pocket of $4,900
SilverSneakers® fitness benefit
$0 medical deductible
$0 copayment for personal doctor (primary care provider) visits
$0 copayment for mail order Tier 1 and 2 drugs at a preferred mail order pharmacy
$0 pharmacy deductible on Tiers 1, 2 and 3
$0 copayment for an annual routine hearing exam
100% coverage for preventive care
Travel coverage

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumSelect (PPO)

Monthly Premium

Annual Medical Deductible

Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

$4,900 Combined in- and out-of-network

Primary Care Provider Visit

Specialist Visit

$50

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

$335 per day, Days 1-6
$0 Days 7 and beyond

Outpatient Hospital Services

$320
$245 at an ambulatory surgical center

Labs

$0-$20

Diagnostic Tests

Such as ultrasound, EKG, stress test

$40

X-rays

$30

Diagnostic Radiology Services– Advanced Imaging

$200

Urgent Care Visit

$50

Emergency Room Visit

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

$90

Air and Ground Ambulance Services

$300

Durable Medical Equipment

Such as insulin pumps¹, CPAP machines, prosthetic devices¹

20% of the cost

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 networkhealth.com/medicare/plan-materials for details

$90 per incident
$100,000
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

$550

Preventive Dental Services²

Up to $550 reimbursed through Pick Your Perks

Medicare-Covered Dental Services

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

$50

Optional Comprehensive Dental Coverage²

$39 monthly premium
Annual Maximum: $1,000

Annual Routine Vision Exam²

$10
$40 reimbursement out-of-network

Diagnostic Eye Exam

To diagnose and treat diseases and conditions of the eye

$50

Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

Over-the-Counter Coverage²

Up to $550 reimbursed through Pick Your Perks

Fitness with SilverSneakers^®²

Included

Routine Hearing Exam²

$0
$40 out-of-network

Diagnostic Hearing Exam

$50

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

$40

Inpatient Mental Health¹

Per admission

$395 per day, Days 1-4
$0 Days 5 and beyond

Opioid Treatment Services

$40

Substance Abuse Services

Outpatient individual or group therapy

$40

Skilled Nursing Facility¹

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

$0 per day, Days 1-20
$188 per day, Days 21-50
$0 Days 51-100

Outpatient Physical¹, Occupational¹, Speech Therapy

$40

Chiropractic Services

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

$20

Medicare-Covered Acupuncture

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

$50

Medicare-Covered Home Health Care Visits¹

Chemotherapy¹

20% of the cost

Radiation Therapy¹

20% of the cost

Acupuncture

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

$10

Non-Emergency Transportation

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

In addition to 24 trips, up to $550 reimbursed through Pick Your Perks for rides to medical appointments and pharmacies

Dialysis

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.

²Visit networkhealth.com/medicare/additional-benefits for more information.

Network PlatinumSelect (PPO) Drug Plan Costs

Annual Drug Deductible

$395
Applies to Tiers 4-5

INITIAL COVERAGE Amount shown is the maximum you will pay, you may pay less.

30-Day Supply
Preferred Pharmacy or Preferred Mail Order Pharmacy
$2 for Tier 1
$8 for Tier 2
$42 for Tier 3
$95 for Tier 4
25% of the cost for Tier 5

90-Day Supply
Preferred Pharmacy
$5 for Tier 1
$20 for Tier 2
$105 for Tier 3
$237 for Tier 4
Tier 5 is not available

31 to 90-Day Supply
Preferred Mail Order Pharmacy
$0 for Tier 1
$0 for Tier 2

90-Day Supply
Preferred Mail Order Pharmacy
$0 for Tier 1
$0 for Tier 2
$105 for Tier 3
$237 for Tier 4
Tier 5 is not available

30-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy
$5 for Tier 1
$15 for Tier 2
$47 for Tier 3
$100 for Tier 4
25% of the cost for Tier 5

90-Day Supply
Standard Pharmacy or Standard Mail Order Pharmacy
$12 for Tier 1
$37 for Tier 2
$117 for Tier 3
$250 for Tier 4
Tier 5 is not available

Coverage Gap

You enter the coverage gap when your total drug costs reach $4,430. 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 $7,050. You pay the greater of $3.95 or 5% of the cost for generic drugs and the greater of $9.85 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 PlatinumSelect (PPO)

Premium

Northeast Medicare Advantage PPO Plan Benefits

Network PlatinumSelect (PPO)

Network PlatinumSelect (PPO) Drug Plan Costs