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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 2025, 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 5 out of 5 stars in 2025.
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 $310.00 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) plan has a $310 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have an $8 copay at a preferred pharmacy, while standard generic drugs have 21% coinsurance. The plan also has an initial coverage phase where you pay the costs for your drugs until your total drug costs reach $2,000. Once you reach $2,000 in out-of-pocket drug costs, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Network Health PremierRx (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a $75 copay for days 1-5 and no copay for days 6-90, outpatient services, and partial hospitalization with a $20 copay. This plan also includes coverage for emergency services with a $125 copay, primary care visits for a $10 copay, and preventive services. The plan also covers hearing exams, vision exams, dental services, home infusion services, dialysis services, medical equipment, diagnostic and radiological services, home health services, and skilled nursing facility (SNF) services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute, with a copay of $75 for days 1-5 and no copay for days 6-90, and Inpatient Hospital Psychiatric. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by the Network Health PremierRx (PPO) plan, including Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center (ASC) Services, all of which require prior authorization. Outpatient Substance Abuse Services are covered, but individual and group sessions are not covered, and Outpatient Blood Services are also not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Network Health PremierRx (PPO) plan. This benefit requires prior authorization and has a $20 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Network Health PremierRx (PPO) plan, but ground ambulance services, air ambulance services, transportation services to plan-approved health-related locations, and transportation services to any health-related locations are not covered. All covered ambulance services require prior authorization and have no copay or coinsurance.
Emergency Services See details
Emergency Services are covered, with a $125 copay and no coinsurance, and the copay is waived if admitted to the hospital within 24 hours. Urgently Needed Services have a $20 copay and no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Network Health PremierRx (PPO) plan covers primary care physician services for a $10 copay, chiropractic services for a $20 copay, occupational therapy services for a $20 copay, physician specialist services for a $20 copay, physical therapy and speech-language pathology services for a $20 copay, and telehealth services with a copay between $0 and $20. Routine chiropractic care, individual and group sessions for mental health specialty services, individual and group sessions for psychiatric services, and podiatry services are not covered.
Preventive Services See details
The Network Health PremierRx (PPO) plan covers preventive services, including annual physical exams, kidney disease education services, and other preventive services. Some additional preventive services are not covered, including health education, in-home safety assessments, personal emergency response systems, and others.
Hearing Services See details
The Network Health PremierRx (PPO) plan covers hearing exams, including routine hearing exams and fitting/evaluation for hearing aids once per year. Prescription hearing aids are covered with a copay between $495 and $1695, and a maximum benefit of $75 every year; however, prescription hearing aids for the inner ear, outer ear, and over-the-ear are not covered, nor are OTC hearing aids.
Vision Services See details
Vision services include coverage for routine eye exams with a $10 copay. Eyewear benefits are partially covered, with contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades not covered.
Dental Services See details
The Network Health PremierRx (PPO) plan covers Medicare Dental Services with no copay, and other dental services with a $30 copay. Some services, such as Orthodontic Services, Restorative Services, and Endodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Network Health PremierRx (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), is covered with no copay and no coinsurance, but Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies and Diabetic Equipment are also covered, but some sub-services are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services are not covered. There is no copay for the covered services.
Home Health Services See details
Home Health Services are covered by the Network Health PremierRx (PPO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Network Health PremierRx (PPO) plan. Specifically, 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 covered, but additional days beyond Medicare-covered and non-Medicare-covered stays are not covered. Prior authorization is required.
Other Services See details
Other Services, including acupuncture, over-the-counter items, and meal benefits, are not covered. Other services such as lipid profile, fasting blood sugar and CBC are covered. Additional services do not require authorization or referral.
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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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