Network Health Medicare Explore (HMO)

$35 per month

Medical and pharmacy coverage with a low monthly premium and low copayments

$35 monthly premium
$0 medical deductible
$0 copayment for 90-day mail order Tier 1 drugs
$0 copayment for primary care provider visits
$10 copayment for an annual eye exam
$90 emergency room visit
100% coverage for preventive care
Prescription drug coverage
Snowbird travel coverage
SilverSneakers^® Fitness benefit
Annual dental exam and cleaning
Hearing aid discount benefit

Services with a ¹ may require prior authorization.

Network Health Medicare Explore HMO Benefits	Network Health Medicare Explore (HMO)
Premium	$35 per month (Includes pharmacy)
Deductible	This plan does not have a medical deductible.
Maximum Out-of-Pocket	$4,900 per year
Inpatient Hospital Coverage¹	Days 1-6 $295/day copayment Days 7 and beyond $0 copayment
Outpatient Surgery Services¹	$295 copayment
Primary Care Provider	$0 copayment
Specialist	$30 copayment
Preventive Care	$0 copayment
Emergency Room	$90 copayment
Urgent Care	$45 copayment
Low Cost Labs	$0 copayment
Lab and Clinical Diagnostic Tests	$15 copayment
Outpatient X-rays	$25 copayment
Ultrasound, EKGs, EEGs, Stress Test	$35 copayment
Radiation Therapy	$60 copayment
Diagnostic Radiology Services (Such as MRIs, CT Scans)	$125 copayment
Medicare Covered Hearing Exams	$10 copayment
Medicare Covered Dental¹	$50 copayment (does not include services in connection with care, treatment, filling, removal or replacement of teeth)
Supplemental Dental	One exam and cleaning per year with Delta Dental Medicare Advantage Provider. $30 copayment
Medicare Covered Eye Exam	$50 copayment
Supplemental Vision	$10 copayment, maximum $30 reimbursement out-of-network
Inpatient Mental Health Care	Days 1-5 $295 copayment/day Days 6-190 $0 copayment including “lifetime reserve days”
Outpatient Mental Health Care	Individual or group therapy $30 copayment
Skilled Nursing Facility¹	Days 1-20 $0 copayment/day Days 21-49 $172 copayment/day Days 50-100 $0 copayment
Physical Therapy	$30 copayment
Ambulance	$225 copayment
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 a subluxation (when 1 or more of the bones of your spine move out of position): $20 copayment
Diabetes Monitoring Supplies and Test Strips¹	One Touch™ and Accu-Chek™ (All other brands are not covered) $0 copayment, applies up to a 90-day supply
Diabetes Self-Monitoring Training¹	$0 copayment
Therapeutic Shoes/Inserts¹	$10 copayment
Durable Medical Equipment	20% of the cost
Prosthetic Devices	20% of the cost
Related Medical Supplies¹	20% of the cost
Home Health Care¹	$0 copayment

This information is not a complete description of benefits. Call 800-378-5237 (TTY 800-947-3529) for more information.

Network Health Medicare Explore (HMO) Drug Plan Costs
When your coverage starts, you pay a deductible for tiers 3, 4 and 5 only; and copayments until total drug costs (what you and Network Health pay) reach $3,820.
Drug Deductible	$260 For tiers 3, 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% 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% 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 $3,820. You pay 37% and Network Health pays 63% for generic drugs. For brand name drugs, you pay 25%, Network Health pays 5% and the drug company pays 70%.
Catastrophic Coverage	You pay the greater of $3.40 or 5% of the cost for generic drugs and $8.50 or 5% of the cost for brand name drugs, once your true out of pocket cost reaches $5,100.

Medicare Plans

Network Health Medicare Explore (HMO)