Network PlatinumPlus (PPO)
H5215 - 001 - 0
(5 / 5)
Network PlatinumPlus (PPO) is a Medicare Advantage (Part C) 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 2024 version using the link below:
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) ?
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 | $215.90 |
- 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) ?