2019 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Network PlatinumChoice (PPO) | ||||
Location: | Outagamie, Wisconsin Click to see other locations | ||||
Plan ID: | H5215 - 011 - 0 Click to see other plans | ||||
Member Services: | 1-800-378-5234 TTY users 1-800-947-3529 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Network PlatinumChoice (PPO) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $25.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $260 (Tier 1 and 2 excluded from the Deductible.) | ||||
Annual Initial Coverage Limit (ICL): | $3,820 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,500 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 5,979 drugs | Browse the Network PlatinumChoice (PPO) Formulary | |||
This plan has 5 drug tiers.
See cost-sharing for all pharmacies and tiers.
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Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $2.00 | $8.00 | $42.00 | $84.00 | 28% |
• Number of Drugs per Tier: | 188 | 1913 | 706 | 2133 | 1039 |
Plan's Pharmacy Search: | http://www.networkhealthmedicare.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Outagamie, Wisconsin: | 3,982 members | ||||
Number of Members enrolled in this plan in Wisconsin: | 20,956 members | ||||
Number of Members enrolled in this plan in (H5215 - 011): | 21,031 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 4 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Base Premium | Part D Supplemental Premium | |
$25.00 | $0.00 | $25.00 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $6.20 | $12.50 | $18.70 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $6.20 | $12.50 | $18.70 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $0 | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $4,500 In and Out-of-network $4,500 In-network | |||||
Optional supplemental benefits | |||||
• Yes | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-Network: No | |||||
Inpatient hospital coverage | |||||
• In-Network: $425 per day for days 1 through 4 $0 per day for days 5 through 90 | |||||
Outpatient hospital coverage | |||||
• In-Network: $395 per visit | |||||
Preventive care | |||||
• In-Network: $0 copay | |||||
Inpatient hospital coverage | |||||
• Out-of-Network: $425 per day for days 1 through 4 $0 per day for days 5 and beyond | |||||
Outpatient hospital coverage | |||||
• Out-of-Network: $395 per visit | |||||
Preventive care | |||||
• Out-of-Network: $0 copay | |||||
Doctor visits | |||||
• Primary: In-Network: $10 per visit | |||||
• Primary: Out-of-Network: $10 per visit | |||||
• Specialist: In-Network: $50 per visit | |||||
• Specialist: Out-of-Network: $50 per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 per visit (always covered) | |||||
• Urgent care: $45 per visit (always covered) | |||||
Transportation | |||||
• Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Skilled Nursing Facility | |||||
• In-Network: $0 per day for days 1 through 20 $172 per day for days 21 through 49 $0 per day for days 50 through 100 | |||||
Ground ambulance | |||||
• In-Network: $275 | |||||
Skilled Nursing Facility | |||||
• Out-of-Network: $0 per day for days 1 through 20 $172 per day for days 21 through 49 $0 per day for days 50 through 100 | |||||
Ground ambulance | |||||
• Out-of-Network: $275 | |||||
Vision | |||||
• Routine eye exam: In-Network: $10 | |||||
• Routine eye exam: Out-of-Network: 100% | |||||
• Other: Not covered | |||||
• Contact lenses: Not covered | |||||
• Eyeglasses (frames and lenses): Not covered | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: In-Network: $295 per day for days 1 through 4 $0 per day for days 5 through 90 | |||||
• Inpatient hospital - psychiatric: Out-of-Network: $295 per day for days 1 through 4 $0 per day for days 5 through 190 | |||||
• Outpatient group therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: $40 | |||||
• Outpatient individual therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: $40 | |||||
• Outpatient group therapy visit: In-Network: $40 | |||||
• Outpatient group therapy visit: Out-of-Network: $40 | |||||
• Outpatient individual therapy visit: In-Network: $40 | |||||
• Outpatient individual therapy visit: Out-of-Network: $40 | |||||
Rehabilitation services | |||||
• Occupational therapy visit: In-Network: $40 | |||||
• Occupational therapy visit: Out-of-Network: $40 | |||||
• Physical therapy and speech and language therapy visit: In-Network: $40 | |||||
• Physical therapy and speech and language therapy visit: Out-of-Network: $40 | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: In-Network: $40 | |||||
• Foot exams and treatment: Out-of-Network: $40 | |||||
• Routine foot care: Not covered | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: 20% per item | |||||
• Diabetes supplies: In-Network: $0 copay | |||||
• Diabetes supplies: Out-of-Network: $0-15 per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: In-Network: 20% | |||||
• Chemotherapy: Out-of-Network: 20% | |||||
• Other Part B drugs: In-Network: 20% | |||||
• Other Part B drugs: Out-of-Network: 20% | |||||
** Benefits Services ** | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: In-Network: $15-35 | |||||
• Diagnostic tests and procedures: Out-of-Network: $15-35 | |||||
• Lab services: In-Network: $0-15 | |||||
• Lab services: Out-of-Network: $0-15 | |||||
• Diagnostic radiology services (e.g., MRI): In-Network: $35-125 | |||||
• Diagnostic radiology services (e.g., MRI): Out-of-Network: $35-125 | |||||
• Outpatient x-rays: In-Network: $30 | |||||
• Outpatient x-rays: Out-of-Network: $15-35 | |||||
Hearing | |||||
• Hearing exam: In-Network: $10 | |||||
• Hearing exam: Out-of-Network: $10 | |||||
• Fitting/evaluation: Not covered | |||||
• Hearing aids: In-Network: $1,220-1,985 | |||||
• Hearing aids: Out-of-Network: $1,220-1,985 | |||||
Preventive dental | |||||
• Office visit: In-Network: $30.00 | |||||
• Office visit: Out-of-Network: 100% | |||||
• Oral exam: Covered under office visit | |||||
• Cleaning: Covered under office visit | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): Not covered | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
** Optional Supplemental Benefits ** | |||||
Package #1 | |||||
• Comprehensive dental, Preventive dental | |||||
• Monthly Premium: $35.00 | |||||
• Deductible: $100.00 |