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Network Health Medicare Bravo (PPO)

H5215 - 014 - 0
5 out of 5 stars (5 / 5)

Network Health Medicare Bravo (PPO) is a Medicare Advantage Plan by Network Health Medicare Advantage Plans.

This page features plan details for 2023 Network Health Medicare Bravo (PPO) H5215 – 014 – 0 available in Southeast Wisconsin.

IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:

2025 Network Health Bravo (PPO) H5215 - 014 - 0

Locations

Network Health Medicare Bravo (PPO) is offered in the following locations.

Kenosha County, Wisconsin
Milwaukee County, Wisconsin
Ozaukee County, Wisconsin

Click to see more locations

Plan Overview

Network Health Medicare Bravo (PPO) offers the following coverage and cost-sharing.

Insurer:Network Health Medicare Advantage Plans
Health Plan Deductible:$0.00
MOOP:$8,000 In and Out-of-network
$4,500 In-network
Drugs Covered:No

Ready to sign up for Network Health Medicare Bravo (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Network Health Medicare Bravo (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.
Part B Part C Part B Give Back Total
$164.90 $0.00 $0.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Network Health Medicare Bravo (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-Network: No

Dental (comprehensive)

Diagnostic services:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Diagnostic services:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Endodontics:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Endodontics:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Extractions:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Extractions:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Non-routine services:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Non-routine services:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Periodontics:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Periodontics:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Restorative services:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Restorative services:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)

Dental (preventive)

Cleaning:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Cleaning:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Dental x-ray(s):In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Dental x-ray(s):Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Fluoride treatment:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Fluoride treatment:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)
Oral exam:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Oral exam:Out-of-Network: 50% coinsurance (no limits) (authorization not required) (referral not required)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI):In-Network: $20-200 copay (authorization required) (referral not required)
Diagnostic radiology services (e.g., MRI):Out-of-Network: $50-250 copay (authorization required) (referral not required)
Diagnostic tests and procedures:In-Network: $20 copay (authorization required) (referral not required)
Diagnostic tests and procedures:Out-of-Network: $30-50 copay (authorization required) (referral not required)
Lab services:In-Network: $0-20 copay (authorization required) (referral not required)
Lab services:Out-of-Network: $30 copay (authorization required) (referral not required)
Outpatient x-rays:In-Network: $35 copay (authorization required) (referral not required)
Outpatient x-rays:Out-of-Network: $40 copay (authorization required) (referral not required)

Doctor visits

Primary:In-Network: $0 copay
Primary:Out-of-Network: $30 copay per visit
Specialist:In-Network: $40 copay per visit (authorization required) (referral not required)
Specialist:Out-of-Network: $75 copay per visit (authorization required) (referral not required)

Emergency care/Urgent care

Emergency: $110 copay per visit (always covered)
Urgent care: $45 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment:In-Network: $40 copay (authorization required) (referral not required)
Foot exams and treatment:Out-of-Network: $75 copay (authorization required) (referral not required)
Routine foot care: Not covered

Ground ambulance

In-Network: $300 copay
Out-of-Network: $300 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

Fitting/evaluation:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Fitting/evaluation:Out-of-Network: $40 copay (limits may apply) (authorization not required) (referral not required)
Hearing aids:In-Network: $495-1,695 copay (limits may apply) (authorization not required) (referral not required)
Hearing aids:Out-of-Network: $495-1,695 copay (limits may apply) (authorization not required) (referral not required)
Hearing exam:In-Network: $40 copay (authorization not required) (referral not required)
Hearing exam:Out-of-Network: $75 copay (authorization not required) (referral not required)

Hospital coverage (inpatient)

In-Network: $295 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization required) (referral not required)
Out-of-Network: $550 per day for days 1 through 6
$0 per day for days 7 and beyond (authorization required) (referral not required)

Hospital coverage (outpatient)

In-Network: $275 copay per visit (authorization required) (referral not required)
Out-of-Network: $450 copay per visit (authorization required) (referral not required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$8,000 In and Out-of-network
$4,500 In-network

Medical equipment/supplies

Diabetes supplies:In-Network: $0 copay (authorization required)
Diabetes supplies:Out-of-Network: $0-30 copay per item (authorization required)
Durable medical equipment (e.g., wheelchairs, oxygen):In-Network: 20% coinsurance per item (authorization required)
Durable medical equipment (e.g., wheelchairs, oxygen):Out-of-Network: 25% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):In-Network: 20% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):Out-of-Network: 25% coinsurance per item (authorization required)

Medicare Part B drugs

Chemotherapy:In-Network: 20% coinsurance (authorization required)
Chemotherapy:Out-of-Network: 50% coinsurance (authorization required)
Other Part B drugs:In-Network: 20% coinsurance (authorization required)
Other Part B drugs:Out-of-Network: 50% coinsurance (authorization required)

Mental health services

Inpatient hospital – psychiatric:In-Network: $395 per day for days 1 through 4
$0 per day for days 5 through 90 (authorization required) (referral not required)
Inpatient hospital – psychiatric:Out-of-Network: $395 per day for days 1 through 4
$0 per day for days 5 through 190 (authorization required) (referral not required)
Outpatient group therapy visit:In-Network: $20 copay (authorization required) (referral not required)
Outpatient group therapy visit:Out-of-Network: $20 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:In-Network: $20 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:Out-of-Network: $20 copay (authorization required) (referral not required)
Outpatient individual therapy visit:In-Network: $20 copay (authorization required) (referral not required)
Outpatient individual therapy visit:Out-of-Network: $20 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:In-Network: $20 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:Out-of-Network: $20 copay (authorization required) (referral not required)

Optional supplemental benefits

No

Preventive care

In-Network: $0 copay (authorization not required) (referral not required)
Out-of-Network: $15 copay (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit:In-Network: $30 copay (authorization required) (referral not required)
Occupational therapy visit:Out-of-Network: $75 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:In-Network: $30 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:Out-of-Network: $75 copay (authorization required) (referral not required)

Skilled Nursing Facility

In-Network: $0 per day for days 1 through 20
$196 per day for days 21 through 45
$0 per day for days 46 through 100 (authorization required) (referral not required)
Out-of-Network: $196 per day for days 1 through 45
$0 per day for days 46 through 100 (authorization required) (referral not required)

Transportation

Not covered

Vision

Contact lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Contact lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames: Not covered (no limits)
Eyeglass lenses: Not covered (no limits)
Eyeglasses (frames and lenses):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses):Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Other: Not covered (no limits)
Routine eye exam:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Routine eye exam:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Upgrades:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Upgrades:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)

Wellness programs (e.g., fitness, nursing hotline)

Covered (authorization not required) (referral not required)

Ready to sign up for Network Health Medicare Bravo (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Table of Contents

Need more information on Network Health Medicare Bravo (PPO)? See 2025 Network Health Medicare Bravo (PPO) at MedicareAdvantageRX.com.

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Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

SMID: MULTIPLAN_HCIHNDOGMED01PY25_M

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