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Network Health PremierRx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Network Health PremierRx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Network Health PremierRx (PPO) in 2026, please refer to our full plan details page.
Network Health PremierRx (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 PremierRx (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 PremierRx (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 PremierRx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $226.00. 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 PremierRx (PPO)
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Drug Coverage
The Network Health PremierRx (PPO) Medicare prescription drug plan features an annual drug deductible of $340. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at preferred pharmacies and preferred mail-order services. Tier 2 generic drugs cost as little as an $8 copay for a 1-month supply at preferred locations, or no copay for a 3-month supply through preferred mail order. Brand-name and specialty medications on this plan are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 23% coinsurance at preferred pharmacies, while Tier 4 non-preferred drugs carry a 25% coinsurance across all pharmacy options. Specialty medications in Tier 5 require a 29% coinsurance for a 1-month supply at both standard and preferred pharmacies.
Additional Benefits
The Network Health PremierRx (PPO) plan offers robust coverage for essential medical services with low out-of-pocket costs. Inpatient hospital stays require a $75 daily copay for the first five days and no copay thereafter, while outpatient hospital services, preventive care, and home health services are available with no copay. Primary care visits require a $10 copay, specialist and therapy visits require a $20 copay, and emergency room visits have a $130 copay, all with no coinsurance. For additional healthcare needs, the plan features no copays or coinsurance for skilled nursing facility admissions, durable medical equipment, and routine hearing exams. Medicare-covered dental care and annual cleanings are covered with no coinsurance, and routine vision exams are available with a $10 copay. Additionally, members benefit from an over-the-counter allowance of up to $85 every three months with no copay or coinsurance.
Inpatient Hospital See details
Network Health PremierRx (PPO) covers inpatient acute hospital stays with no coinsurance, requiring prior authorization, a $75 daily copay for days 1 to 5, and no copay for days 6 and beyond, though upgrades and non-Medicare stays are not covered. Inpatient psychiatric care is also covered with no copay, no coinsurance, and prior authorization required, but additional days and non-Medicare-covered stays are excluded.
Outpatient Services See details
Network Health PremierRx (PPO) covers outpatient services, including outpatient hospital, ambulatory surgical center, and blood services, with no copay and no coinsurance. Some outpatient substance abuse services are covered, but individual and group sessions are not covered.
Partial Hospitalization See details
Network Health PremierRx (PPO) covers partial hospitalization services with a $20.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are offered by Network Health PremierRx (PPO) with no copay and no coinsurance, but ground ambulance, air ambulance, and health-related transportation services are not covered.
Emergency Services See details
Network Health PremierRx (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $20 copay and no coinsurance, while worldwide emergency and urgent care are partially covered with a $130 copay and no coinsurance up to a $100,000 maximum benefit, though worldwide emergency transportation is not covered.
Primary Care See details
Network Health PremierRx (PPO) covers primary care physician services with a $10 copay and no coinsurance, and specialist visits, occupational therapy, and physical therapy with a $20 copay and no coinsurance. Opioid treatment has no copay and no coinsurance, and telehealth ranges from a $0 to $20 copay with no coinsurance, while podiatry, chiropractic, mental health specialty, and psychiatric services are not covered.
Preventive Services See details
Network Health PremierRx (PPO) covers preventive services, such as annual physical exams and kidney disease education, with no copay and no coinsurance. While a memory fitness benefit is covered, several other supplemental preventive services—including health education, in-home safety assessments, and medical nutrition therapy—are not covered.
Hearing Services See details
Network Health PremierRx (PPO) covers hearing services, offering one routine hearing exam and fitting evaluation per year with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays between $495 and $1,695 up to a $75 annual maximum, though over-the-counter, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Network Health PremierRx (PPO) partially covers vision services, offering one routine eye exam per year with a $10 copay and no coinsurance, up to a $40 annual maximum. Other eye exams and eyewear, including contacts and eyeglasses, are not covered under this plan.
Dental Services See details
Network Health PremierRx (PPO) provides partially covered dental services, featuring Medicare-covered dental care with no copay and no coinsurance, and annual exams and cleanings with no coinsurance. Other preventive services require a $30 copay and no coinsurance up to a $100 annual maximum, but restorative, endodontic, periodontic, prosthodontic, oral surgery, implant, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Network Health PremierRx (PPO) with no copay, while associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance. Part B insulin is also covered with a $35 copay and no coinsurance to 20% coinsurance, subject to prior authorization and step therapy guidelines.
Dialysis Services See details
Dialysis Services are covered under the Network Health PremierRx (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Network Health PremierRx (PPO) covers durable medical equipment with no copay and no coinsurance, subject to prior authorization. While some prosthetics, medical supplies, and diabetic equipment services are covered with no copay and no coinsurance, prosthetic devices, medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Network Health PremierRx (PPO) diagnostic and radiological services are available with no copay and no coinsurance, subject to prior authorization. Although some services are covered, diagnostic procedures/tests, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient x-ray services are not covered.
Home Health Services See details
Home Health Services are covered by Network Health PremierRx (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Network Health PremierRx (PPO) covers some services under Cardiac Rehabilitation Services with no copay and no coinsurance, although Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Network Health PremierRx (PPO) with no copay and no coinsurance per admission, though prior authorization is required. While the plan allows for admission without a prior three-day inpatient hospital stay, additional days beyond standard Medicare-covered days are not covered.
Other Services See details
Network Health PremierRx (PPO) provides partial coverage for other services, which includes select lab tests and over-the-counter items up to $85 every three months with no copay and no coinsurance. Acupuncture, meal benefits, and other additional services are not covered under this plan.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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