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Network Health PlusRx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Network Health PlusRx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Network Health PlusRx (PPO) in 2025, please refer to our full plan details page.
Network Health PlusRx (PPO) is a PPO plan offered by Network Health, Inc. available for enrollment in 2025 to people living in East Central Wisconsin. This plan received an overall rating of 5 out of 5 stars in 2025.
It's important to know that Network Health PlusRx (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Network Health PlusRx (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Network Health PlusRx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $73.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.50. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $370.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $3400.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $3400.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Network Health PlusRx (PPO) plan has a $370 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have an $8 copay at preferred pharmacies. The plan offers an "Enhanced Alternative" drug benefit type. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you will pay nothing for covered drugs.
Additional Benefits
The Network Health PlusRx (PPO) plan provides comprehensive coverage for various healthcare services. This plan includes inpatient hospital stays with a copay, and outpatient services with copays varying from $0 to $350. Additional benefits include coverage for emergency services, primary care, preventive services, hearing, vision, and dental care, each with specific copays and limitations. The plan also covers home health services, dialysis, and medical equipment, with varying cost-sharing structures.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but require prior authorization. For Inpatient Hospital-Acute, you pay a $175 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you pay a $150 copay for days 1-10, and no copay for days 11-90.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay of $0-$350, observation services with a $350 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $20 copay for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay a $40 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Network Health PlusRx (PPO) plan. Ground and Air Ambulance Services have a $250 copay, and there is no coinsurance; however, Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered by the Network Health PlusRx (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $40 copay, and there is no coinsurance for either. Worldwide Emergency Coverage and Worldwide Urgent Coverage are covered with a $125 copay, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Network Health PlusRx (PPO) plan covers primary care physician services with a $15 copay, chiropractic services with a $20 copay (prior authorization required), and occupational therapy services with a $40 copay (prior authorization required). Physician specialist services have a $40 copay, while mental health and psychiatric services have a $35 copay for individual and group sessions (prior authorization required). Physical therapy and speech-language pathology services have a $40 copay (authorization required), and additional telehealth benefits have a copay between $0 and $40. Opioid treatment program services are covered with a copay of $35 (prior authorization required), and Podiatry services are not covered.
Preventive Services See details
The Network Health PlusRx (PPO) plan covers preventive services, including an annual physical exam with no copay. Other preventive services, such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, are covered. However, health education, in-home safety assessments, and several other services are not covered.
Hearing Services See details
Hearing Services includes routine hearing exams with a $25 copay, and fitting/evaluation for hearing aids. Prescription hearing aids are covered, with a copay between $495 and $1695 depending on the type of hearing aid; however, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay, and routine eye exams with a $10 copay for one visit per year, but eyewear is partially covered, and does not include coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, or upgrades.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $25 copay, and other dental services with a $750 annual maximum. Preventive services include oral exams (2 per year), dental x-rays (1 per year), other diagnostic services (unlimited), cleanings (2 per year), fluoride treatment (1 per year), and other preventive services (unlimited). Restorative, Adjunctive General, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, and Oral and Maxillofacial Surgery are covered with 50% coinsurance. Implant Services and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by Network Health PlusRx (PPO). You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0% to 20% coinsurance and a $0 copay, Prosthetics/Medical Supplies with coinsurance for Medicare-covered Prosthetic Devices and Medical Supplies, and Diabetic Equipment with copays for Medicare-covered Diabetes Supplies and Diabetic Therapeutic Shoes or Inserts. Durable Medical Equipment for use outside the home is not covered, and Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Network Health PlusRx (PPO) plan. Diagnostic Procedures/Tests have a copay between $5 and $25, while Lab Services have no copay. Diagnostic Radiological Services have a copay between $25 and $100, Therapeutic Radiological Services have a $60 copay, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Network Health PlusRx (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a copay for some services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $20, for days 21-40 the copay is $214, and for days 41-100 there is no copay.
Other Services See details
The Network Health PlusRx (PPO) plan covers Over-the-Counter (OTC) items, with a maximum benefit of $75.00 every three months, including nicotine replacement therapy and Naloxone. Other services like acupuncture, meal benefits, and various other services are not covered.
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