Network Health Medicare Go (PPO)


Medicare Plan Details

2020 Plan
Monthly Premium
(select county for price)

 

by Network Health Medicare Advantage Plans
Additional Coverage
Hearing Vision
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
$5,900 In and Out-of-network
$5,900 In-network
No
Yes
Yes
No

Medical Benefits

Doctor Services

In-network: $10 per visit
Out-of-network: $20 per visit
In-network: $45 per visit
Out-of-network: $75 per visit

Tests, labs, & imaging

In-network: $20-40
Out-of-network: $30-50
In-network: $0-20
Out-of-network: $30-50
In-network: $40-125
Out-of-network: $50-140
In-network: $35
Out-of-network: $30-50
$90 per visit (always covered)
$10-45 per visit (always covered)

Hospital Services

In-network: $395 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: $495 per day for days 1 through 5
$0 per day for days 6 and beyond
In-network: $385 per visit
Out-of-network: $415 per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$178 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
$178 per day for days 21 through 57
$0 per day for days 58 through 100

Preventive services

In-network: $0 copay
Out-of-network: $15

Ambulance

In-network: $275
Out-of-network: $275

Therapy services

In-network: $40
Out-of-network: $75
In-network: $40
Out-of-network: $75

Mental health services

In-network: $40
Out-of-network: $30-50
In-network: $40
Out-of-network: $30-50
In-network: $40
Out-of-network: $30-50
In-network: $40
Out-of-network: $30-50

Opioid treatment services

Covered

Other services

In-network: 20% per item
Out-of-network: 25-50% per item
In-network: 20% per item
Out-of-network: 25-50% per item
In-network: $0 copay
Out-of-network: $0-10 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 :
$3.60 copay or 5% (whichever costs more)

Brand-name drugs :
$8.95 copay or 5% (whichever costs more)

Generic$14.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug
Specialty Tier27%

Part B Drugs

In-network: 20%
Out-of-network: 25-50%
In-network: 20%
Out-of-network: 25-50%

Extra Benefits

Hearing

In-network: $15
Out-of-network: $25
Not covered
In-network: $1,220-1,985
Out-of-network: $1,220-1,985

Preventive Dental

Not covered
Not covered
Not covered
Not covered

Comprehensive dental

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Vision

In-network: $10
Out-of-network: $0 copay
Not covered
Not covered
Not covered
Not covered
Not covered

Other benefits

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

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