Network Health Premier (PPO)
H5215 - 006 - 0
(5 / 5)
Network Health Premier (PPO) is a Medicare Advantage (Part C) Plan by Network Health Medicare Advantage Plans.
This page features plan details for 2024 Network Health Premier (PPO) H5215 – 006 – 0 available in East Central Wisconsin.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Network Health Premier (PPO) is offered in the following locations.
Plan Overview
Network Health Premier (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 Premier (PPO) ?
Premium Breakdown
Network Health Premier (PPO) has a monthly premium of $95.00. 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 | $95.00 | $0.00 | $269.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Network Health Premier (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 | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $20 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network Specialist | $20 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 | $20 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $0 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 | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network | $0 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $20 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 copay (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | $0 copay (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 | $75 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 | $75 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 | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $0 copay per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $42.00 |
| Deductible | $100.00 |
Ready to sign up for Network Health Premier (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
Factsonmedicare.com is a free-to-use informational website by Dog Media Solutions LLC. All insurance agents and enrollment platforms linked to this site have their own terms and conditions.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B Premium give-back is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do feature in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
HealthCompare Insurance Services does not offer every plan available in your area. Currently we represent 18 organizations, which offers 52,101 products in your area.
We do not feature every plan available in your area. Any information we provide is limited to those plans we do feature in your area. Enrollment is offered through our partners including HealthCompare Insurance Services Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
HealthCompare Insurance Services represents Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.
Medicare has neither approved nor endorsed any information on this site.