Network Health | Network Health Go (PPO)

Network Health 2024 Medicare Advantage PPO plans are rated 5 out of 5 stars by Medicare. Learn more.

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Plan Details

Network Health Go (PPO)

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

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$1,525 Pick Your Perks flexible benefits program available, covering dental, vision hardware, over-the-counter items, acupuncture, massage therapy and more
Prescription drug coverage
Annual maximum out-of-pocket of $3,900 in-network
SilverSneakers® Fitness benefit
$0 medical deductible
$0 copayment for in-network personal doctor (primary care provider) visits
$0 pharmacy deductible on Tiers 1 and 2
$35 copayment for in-network specialist visit
$0 copayment for 31- to 100-day supply for Tier 1 and 31- to 90-day supply for Tier 2 drugs at preferred mail order
$10 copayment for an annual routine vision exam
100% coverage for preventive care
Freedom to see in- and out-of-network providers (costs may be lower when seeing in-network providers)
Travel coverage

Southeast Medicare Advantage PPO Plan Benefits

Network Health Go (PPO)

Monthly Premium

Annual Medical Deductible

Annual Maximum Out-of-Pocket

(Does not include Part D prescription drugs)

In-Network: $3,900
Out-of-Network: $6,500

Primary Care Provider Visit

In-Network: $0
Out-of-Network: $30

Specialist Visit

In-Network: $35
Out-of-Network: $75

Preventive Care*

In-Network: $0
Out-of-Network: $15

Annual Medicare Wellness Visit

In-Network: $0
Out-of-Network: $15

Medicare-Covered Vaccines

Flu, pneumonia, COVID-19

Part B Vaccines

Hepatitis B, all other Part B vaccines

In-Network: $0
Out-of-Network: $15

Inpatient Hospital Services¹

Per admission

In-Network: $295 per day, days 1-6
$0 days 7 and beyond

Out-of-Network: $550 per day, days 1-6
$0 days 7 and beyond

Outpatient Hospital Services

In-Network: $275
$225 at an ambulatory surgical center

Out-of-Network: $450
$450 at an ambulatory surgical center

Labs

In-Network: $0-$20
Out-of-Network: $30

Diagnostic Tests

Such as ultrasound, EKG, stress test

In-Network: $20
Out-of-Network: $50

X-rays

In-Network: $35
Out-of-Network: $45

Diagnostic Radiology Services– Advanced Imaging

In-Network: $200
Out-of-Network: $250

Urgent Care Visit
Free-standing facility

$45

Emergency Room Visit

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

$110

Air and Ground Ambulance Services

$275

Durable Medical Equipment

Such as insulin pumps¹, CPAP machines, prosthetic devices¹

In-Network: 20% of the cost
Out-of-Network: 25% of the cost

Home Infusion Supplies

In-Network: $0
Out-of-Network: 25% 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 services²

In-network: $0

Medicare Part B Drugs¹

Plan will apply the CMS published adjusted beneficiary coinsurance as required under the Inflation Reduction Act.

In-Network: 20% of the cost
Out-of-Network: 50% of the cost

Travel within the United States

Receive in-network coverage when you see a provider outside Wisconsin and within the United States territories. You can see any provider who accepts Medicare beneficiaries.

International Emergency Coverage

View the Evidence of Coverage at networkhealth.com/medicare/plan-materials for details

$110 per incident
$100,000
Maximum benefit

Pick Your Perks²

Reimbursement for the following extra benefits: dental services, vision hardware, 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

$1,525

Dental Services^{2, 3}

Up to $1,525 reimbursed through Pick Your Perks

Medicare-Covered Dental Services

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

In-Network: $35
Out-of-Network: $75

Optional Comprehensive Dental Coverage²

$42 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

In-Network: $35
Out-of-Network: $75

Post-Cataract Eyewear

One pair of eyeglasses or contact lenses after each cataract surgery

In-Network: $0
Out-of-Network: $75

Additional Eyewear

Up to $1,525 reimbursement through Pick Your Perks

Over-the-Counter Coverage²

Up to $1,525 reimbursed through Pick Your Perks

Fitness with SilverSneakers^®²

Included

Routine Hearing Exam²

In-Network: $0
Out-of-Network: $40

Diagnostic Hearing Exam

In-Network: $35
Out-of-Network: $75

Hearing Aids²

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

$495-$1,695 per device
Hearing aids must be purchased through TruHearing
No coverage out-of-network

Outpatient Mental Health

Individual or group therapy

In-Network: $40
Out-of-Network: $50

Inpatient Mental Health¹

Per admission

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

Opioid Treatment Services

In-Network: $40
Out-of-Network: $50

Substance Abuse Services

Outpatient individual or group therapy

In-Network: $40
Out-of-Network: $50

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
$203 per day, days 21-45
$0 days 46-100

Outpatient Physical¹, Occupational¹, Speech Therapy

In-Network: $40
Out-of-Network: $75

Chiropractic Services

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

In-Network: $20
Out-of-Network: $40

Medicare-Covered Acupuncture

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

In-Network: $35
Out-of-Network: $75

Medicare-Covered Home Health Care Visits¹

In-Network: $0
Out-of-Network: $15

Chemotherapy¹

In-Network: 20% of the cost
Out-of-Network: 50% of the cost

Radiation Therapy¹
Per service

In-Network: 20% of the cost
Out-of-Network: 25% of the cost

Acupuncture

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

Diabetes Monitoring Supplies and Test Strips

One Touch^™ and Accu-Chek^™ test strips
Continuous glucose monitoring supplies limited to eligible FreeStyle Libre^® and Dexcom^® obtained through your pharmacy. All other brands are not covered.

$0 for up to a 90-day supply

Part B Insulin

One-month supply

In-Network: 20% of the cost, up to $35
Out-of-Network: 50% of the cost

Diabetic Shoe Inserts

Copayment per pair

In-Network: $10
Out-of-Network: $30

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 $1,525 reimbursed through Pick Your Perks for rides to medical appointments and pharmacies

Dialysis

In-Network: 20% of the cost
Out-of-Network: 25% 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/extra-benefits for more information.

³Visit networkhealth.com/medicare/plan-materials to view the full dental Certificate of Coverage document

Network Health Go (PPO) Drug Costs

Annual Drug Deductible

$195 Applies to Tiers 3-5

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
30% of the cost for Tier 5

3-Month Supply
Preferred Pharmacy
100-day for Tier 1
90-day for Tier 2-4

$5 for Tier 1
$20 for Tier 2
$105 for Tier 3
$237 for Tier 4
Tier 5 is not available

31 to 100-Day Supply
Preferred Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2-4

$0 for Tier 1
$0 for Tier 2

3-Month Supply
Preferred Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2-4

$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
$7 for Tier 1
$15 for Tier 2
$47 for Tier 3
$100 for Tier 4
30% of the cost for Tier 5

3-Month Supply
Standard Pharmacy or Standard Mail Order Pharmacy
100-day supply for Tier 1
90-day supply for Tier 2-4

$17 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 $5,030. 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 $8,000. You pay $0.

Part D Insulin
One-month supply

$35

Part D Vaccines
Shingrix, Tdap, all other adult ACIP recommended vaccines

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.

Enroll Now

Copyright 2024 Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. Network Health Cares is a PPO D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. Each year, Medicare evaluates plans based on a 5-Star rating system. 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. Y0108_4790-01-0923_2024_D Last Updated Apr 30, 2024 11:30 AM

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