Network PlatinumSelect (PPO)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by Network Health Medicare Advantage Plans
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
 4.5
out of 5 stars

State: Wisconsin

Select your county to view the price for this plan

 


Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$4,900 In and Out-of-network
$4,900 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

In-network: $0 copay
Out-of-network: $0 copay
In-network: $50 copay per visit
Out-of-network: $50 copay per visit

Tests, labs, & imaging

In-network: $20-40 copay
Out-of-network: $20-40 copay
In-network: $0-20 copay
Out-of-network: $0-20 copay
In-network: $40-200 copay
Out-of-network: $40-200 copay
In-network: $30 copay
Out-of-network: $30 copay
$90 copay per visit (always covered)
$0-50 copay per visit (always covered)

Hospital Services

In-network: $400 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: $400 per day for days 1 through 5
$0 per day for days 6 and beyond
In-network: $395 copay per visit
Out-of-network: $395 copay per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 57
$0 per day for days 58 through 100
Out-of-network: $0 per day for days 1 through 20
$184 per day for days 21 through 57
$0 per day for days 58 through 100

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $300 copay
Out-of-network: $300 copay

Therapy services

In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay

Mental health services

In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay
In-network: $40 copay
Out-of-network: $40 copay

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: $0 copay
Out-of-network: $0-10 copay per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$4.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$3.70 copay or 5% (whichever costs more)

Brand-name drugs :
$9.20 copay or 5% (whichever costs more)

Generic$14.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug
Specialty Tier25%

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Extra Benefits

Hearing

In-network: $50 copay
Out-of-network: $50 copay
Not covered
In-network: $795-2,370 copay
Out-of-network: $795-2,370 copay

Preventive Dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Vision

In-network: $10 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Other benefits

Not covered
Limited coverage
Not covered
Not covered
Limited coverage
Limited coverage
Limited coverage
 4.5
 4
 4
 4
 5
 4
 5
 4
 5
 4
 5

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