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Network Health Choice (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Network Health Choice (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Network Health Choice (PPO) in 2025, please refer to our full plan details page.
Network Health Choice (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 Choice (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 Choice (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 Choice (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $19.00. 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 $300.00 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 $4000.00 (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 $4000.00 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 Choice (PPO)
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Drug Coverage
The Network Health Choice (PPO) plan has an "Enhanced Alternative" drug benefit type. The plan has a $300 deductible. In the initial coverage phase, after you pay your deductible, your cost for drugs will vary based on the tier and pharmacy. For example, you will pay an $8 copay for preferred generic drugs at a preferred pharmacy. After your total drug costs reach $2000, you will enter the catastrophic coverage phase where you will pay nothing for covered drugs.
Additional Benefits
The Network Health Choice (PPO) plan provides a wide range of benefits, including inpatient and outpatient hospital services, with varying copays depending on the service. The plan covers emergency services, primary care, preventive services, and offers coverage for hearing, vision, and dental services, each with specific copays and maximum benefits. Additionally, the plan covers home health services, skilled nursing facilities, and offers benefits for medical equipment, dialysis, and diagnostic services, with some services requiring prior authorization.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $315 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you pay a $295 copay for days 1-4, and no copay for days 5-90. Additional Days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $300, observation services with a $300 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a $40 copay for both individual and group sessions. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Network Health Choice (PPO) plan, but prior authorization is required. The plan has a $45 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and Air Ambulance Services have a $275 copay, with no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Network Health Choice (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $45 copay; all services have no coinsurance. Worldwide Urgent Coverage also has a $125 copay, and Worldwide Emergency Transportation is not covered.
Primary Care See details
The Network Health Choice (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, physician specialist services have a $45 copay, physical therapy and speech-language pathology services have a $40 copay, and additional telehealth benefits have a $0-$45 copay; all other services have a $40 copay minimum.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams, and additional preventive services. Some additional preventive services, like Health Education, In-Home Safety Assessment, and Personal Emergency Response System (PERS) are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $45 copay, and fitting/evaluation for hearing aids, both covered once per year. Prescription hearing aids are covered with a copay between $495 and $1695 depending on the type of hearing aid, but inner ear, outer ear, and over-the-ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services includes coverage for eye exams with a $45 copay, and routine eye exams with no copay. Eyewear has a combined maximum benefit of $200 per year, while contact lenses and eyeglasses (lenses and frames) are covered. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Network Health Choice (PPO) plan covers dental services, with a $45 copay for Medicare dental services. Other dental services have a $1,500 maximum benefit per year. The plan covers oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatments, and other preventive dental services. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, and Oral and Maxillofacial Surgery are covered with 50% coinsurance, and Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Network Health Choice (PPO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with no copay and 0-20% coinsurance, Prosthetics/Medical Supplies with no copay and coinsurance for Medicare-covered devices, and Diabetic Equipment with a copay for Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Network Health Choice (PPO) plan. Diagnostic Procedures/Tests have a copay between $40 and $90, and Lab Services have no copay. Diagnostic Radiological Services have a copay between $90 and $295, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $90 copay.
Home Health Services See details
Home Health Services are covered by the Network Health Choice (PPO) plan with no copay or 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 Choice (PPO) plan. The plan also does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, for days 21-45 the copay is $214, and for days 46-100, there is no copay.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items with a maximum benefit of $25 every three months, and "Other 1" which covers lipid profiles, fasting blood sugar, and CBC. Acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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