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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 2026, 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 4.5 out of 5 stars in 2026.
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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $340.00 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:
Sign up for Network Health PlusRx (PPO)
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Drug Coverage
The Network Health PlusRx (PPO) plan features an annual drug deductible of $340 before coverage begins. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at preferred pharmacies and through preferred mail order. Tier 2 generic drugs carry an $8 copay for a 1-month supply at preferred pharmacies, while standard pharmacies charge a $17 copay. For brand-name and specialty medications, costs are based on coinsurance rather than set copays. Tier 3 preferred brand drugs require 23% coinsurance at preferred pharmacies and 25% coinsurance at standard pharmacies. Tier 4 non-preferred drugs have a 25% coinsurance, while Tier 5 specialty drugs require 29% coinsurance across all pharmacy and mail-order options.
Additional Benefits
The Network Health PlusRx (PPO) plan offers comprehensive medical coverage with predictable cost-sharing, featuring no coinsurance for many core services. Inpatient acute hospital stays require a $175 daily copay for the first five days, while primary care visits have a $15 copay and specialist visits require a $40 copay. Emergency room visits have a $130 copay, which is waived if you are admitted, and urgent care services are available with a $40 copay. For everyday wellness, the plan provides preventive services, home health care, and select lab tests with no copay. Dental care includes preventive services with no copay up to a $750 annual limit, while routine hearing and vision exams are available with a $25 copay or less. Additionally, members benefit from a $140 allowance every three months for over-the-counter items to help manage out-of-pocket health expenses.
Inpatient Hospital See details
Network Health PlusRx (PPO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization and excluding upgrades and non-Medicare-covered stays. Acute care requires a $175 copay per day for days 1 to 5 and no copay for unlimited additional days, while psychiatric care requires a $150 copay per day for days 1 to 10 with no coverage for additional days.
Outpatient Services See details
Under Network Health PlusRx (PPO), outpatient services are covered with no coinsurance, featuring a $350 copay for outpatient hospital, observation, and ambulatory surgical center services, which require prior authorization. Outpatient substance abuse individual and group sessions have a $20 copay and no coinsurance, while outpatient blood services are available with no copay and no coinsurance.
Partial Hospitalization See details
Network Health PlusRx (PPO) covers partial hospitalization services with a $40.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
Network Health PlusRx (PPO) covers Medicare-covered ground and air ambulance services with a $250 copay and no coinsurance, subject to prior authorization. Transportation services to plan-approved or any health-related locations are not covered under this plan.
Emergency Services See details
Emergency services under the Network Health PlusRx (PPO) plan are covered with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, while urgently needed services require a $40 copay and no coinsurance. Worldwide emergency and urgent care are partially covered up to a $100,000 maximum with a $130 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits are covered by Network Health PlusRx (PPO) with a $15 copay and no coinsurance, while specialist and therapy services require a $40 copay and no coinsurance. Mental health, psychiatric, and opioid treatment services have a $35 copay with no coinsurance, and telehealth ranges from no copay to a $40 copay, though chiropractic and podiatry services are not covered.
Preventive Services See details
Network Health PlusRx (PPO) preventive services are partially covered with no copay and no coinsurance for annual physicals, kidney disease education, and memory fitness. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access, home safety modifications, and counseling are not covered.
Hearing Services See details
Network Health PlusRx (PPO) covers hearing services, offering one routine hearing exam and fitting yearly for a $25 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay between $495 and $1,695, while OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services under Network Health PlusRx (PPO) are partially covered, featuring eye exams with a $25 copay (or a $10 copay for one routine exam per year) and no coinsurance, up to a $40 annual maximum. For eyewear, some services are covered with no copay and no coinsurance, but contact lenses, eyeglasses, lenses, frames, and upgrades are not covered.
Dental Services See details
Network Health PlusRx (PPO) partially covers dental services, excluding implant services and orthodontics. Medicare-covered dental services require a $25 copay and no coinsurance, preventive care is covered with no copay and no coinsurance up to a $750 annual limit, and comprehensive services require no copay and a 50% coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Network Health PlusRx (PPO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and radiation, have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Network Health PlusRx (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Network Health PlusRx (PPO) partially covers medical equipment, as diabetic supplies are not covered. Covered durable medical equipment, prosthetics, and medical supplies require no copay and 0% to 20% coinsurance, while diabetic therapeutic shoes and inserts are covered with a $10 copay and no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Network Health PlusRx (PPO) with no coinsurance, though prior authorization is required. Lab services feature no copay, while diagnostic procedures cost between $5 and $25, outpatient X-rays and diagnostic radiology require a minimum $25 copay, and therapeutic radiology requires a minimum $60 copay.
Home Health Services See details
Home Health Services are covered under Network Health PlusRx (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Network Health PlusRx (PPO) with no coinsurance, although only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered and require a $20 copay.
Skilled Nursing Facility (SNF) See details
Network Health PlusRx (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a daily copay of $20 for days 1 through 20, $218 for days 21 through 40, and no copay for days 41 through 100. Prior authorization is required for these services, and additional days beyond the standard 100 Medicare-covered days are not covered.
Other Services See details
Other Services under Network Health PlusRx (PPO) are partially covered, offering Over-the-Counter (OTC) items up to $140 every three months and select lab tests (lipid profile, fasting blood sugar, and CBC) with no copay and no coinsurance. Acupuncture and meal benefits are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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