Network Health Plus (PPO)
H5215 - 001 - 0
(5 / 5)
Network Health Plus (PPO) is a Medicare Advantage (Part C) Plan by Network Health Medicare Advantage Plans.
This page features plan details for 2024 Network Health Plus (PPO) H5215 – 001 – 0 available in East Central Wisconsin.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Network Health Plus (PPO) is offered in the following locations.
Plan Overview
Network Health Plus (PPO) offers the following coverage and cost-sharing.
| Insurer: | Network Health Medicare Advantage Plans |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,400 In and Out-of-network $3,400 In-network |
| Drugs Covered: | No |
Ready to sign up for Network Health Plus (PPO) ?
Premium Breakdown
Network Health Plus (PPO) has a monthly premium of $42.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $42.00 | $0.00 | $216.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Network Health Plus (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,400 In and Out-of-network $3,400 In-network |
| Yes |
| In-network | No |
| In-network | $350 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $350 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $15 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $15 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $40 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network Specialist | $40 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $110 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $40 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $5-25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $5-25 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0-5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0-5 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $25-100 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $25-100 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $25 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $40 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $495-1,695 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $495-1,695 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Office visit | $30.00 (Authorization is not required.) (Referral is not required.) |
| out-of-network Office visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| Oral exam | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | Covered under office visit (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $10 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| In-network | $250 copay (Not applicable.) (Not applicable.) |
| out-of-network | $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $40 copay (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | $0-10 copay per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $175 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | $175 per day for days 1 through 5 $0 per day for days 6 and beyond (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $150 per day for days 1 through 10 $0 per day for days 11 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $150 per day for days 1 through 10 $0 per day for days 11 through 190 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network | $20 per day for days 1 through 20 $203 per day for days 21 through 40 $0 per day for days 41 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $20 per day for days 1 through 20 $203 per day for days 21 through 40 $0 per day for days 41 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $42.00 |
| Deductible | $100.00 |
Ready to sign up for Network Health Plus (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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