Network PlatinumPlus (PPO)
H5215 - 001 - 0
(5 / 5)
Network PlatinumPlus (PPO) is a Medicare Advantage Plan by Network Health Medicare Advantage Plans.
This page features plan details for 2023 Network PlatinumPlus (PPO) H5215 – 001 – 0 available in East Central Wisconsin.
IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Network PlatinumPlus (PPO) is offered in the following locations.
Plan Overview
Network PlatinumPlus (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 PlatinumPlus (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 PlatinumPlus (PPO) has a monthly premium of $51.00. 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 | $51.00 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Network PlatinumPlus (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: | Not covered (no limits) |
| Endodontics: | Not covered (no limits) |
| Extractions: | Not covered (no limits) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | Not covered (no limits) |
Dental (preventive)
| Cleaning: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | Not covered (no limits) |
| Fluoride treatment: | Not covered (no limits) |
| Office visit: | In-Network: $30.00 (authorization not required) (referral not required) |
| Office visit: | Out-of-Network: $0 copay (authorization not required) (referral not required) |
| Oral exam: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $25-100 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: $25-100 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $5-25 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: $5-25 copay (authorization required) (referral not required) |
| Lab services: | In-Network: $0-5 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: $0-10 copay (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: $25 copay (authorization required) (referral not required) |
Doctor visits
| Primary: | In-Network: $15 copay per visit |
| Primary: | Out-of-Network: $15 copay per visit |
| Specialist: | In-Network: $40 copay per visit (authorization required) (referral not required) |
| Specialist: | Out-of-Network: $40 copay per visit (authorization required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $110 copay per visit (always covered) |
| Urgent care: | $40 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: $40 copay (authorization required) (referral not required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $250 copay | |
| Out-of-Network: $250 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: $25 copay (authorization not required) (referral not required) |
| Hearing exam: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| In-Network: $175 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
| Out-of-Network: $175 per day for days 1 through 5 $0 per day for days 6 and beyond (authorization required) (referral not required) |
Hospital coverage (outpatient)
| In-Network: $350 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: $350 copay per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $3,400 In and Out-of-network $3,400 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay (authorization required) |
| Diabetes supplies: | Out-of-Network: $0-10 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: 20% 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: 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $150 per day for days 1 through 10 $0 per day for days 11 through 90 (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: $150 per day for days 1 through 10 $0 per day for days 11 through 190 (authorization required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $35 copay (authorization required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: $35 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $35 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $35 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $35 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: $35 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $35 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $35 copay (authorization required) (referral not required) |
Optional supplemental benefits
| Yes |
Preventive care
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: $40 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $40 copay (authorization required) (referral not required) |
Skilled Nursing Facility
| In-Network: $20 per day for days 1 through 20 $196 per day for days 21 through 40 $0 per day for days 41 through 100 (authorization required) (referral not required) | |
| Out-of-Network: $20 per day for days 1 through 20 $196 per day for days 21 through 40 $0 per day for days 41 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | Not covered (no limits) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | Not covered (no limits) |
| Other: | Not covered (no limits) |
| Routine eye exam: | In-Network: $10 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: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $39.00 |
| Preventive dental: | Deductible: | $100.00 |
| Comprehensive dental: | Monthly Premium: | $39.00 |
| Comprehensive dental: | Deductible: | $100.00 |
Ready to sign up for Network PlatinumPlus (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