A non-government entity
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 2026, 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 4.5 out of 5 stars in 2026.
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 $24.00. 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 $4700.00 (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 $4700.00 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) Medicare plan features a $300 annual drug deductible before coverage begins. For Tier 1 preferred generic drugs, copays are as low as $1 for a one-month supply at preferred pharmacies, with no copay required for a three-month supply filled via preferred mail order. Tier 2 generic medications cost an $8 copay for a one-month supply at preferred locations, which also drops to no copay for a three-month preferred mail-order supply. Brand-name and specialty drugs under this PPO plan require coinsurance instead of flat copays. Tier 3 preferred brand drugs require 23% coinsurance at preferred pharmacies and 25% at standard pharmacies. Tier 4 non-preferred drugs have a 28% coinsurance, while Tier 5 specialty medications carry a 29% coinsurance across all pharmacy and mail-order options.
Additional Benefits
The Network Health Choice (PPO) plan provides comprehensive medical coverage with no deductible and no copay for primary care physician visits, annual physicals, and preventive screenings. For hospital care, inpatient acute stays require a $315 daily copay for the first seven days with no copay thereafter, while outpatient hospital visits carry a $300 copay. Emergency room visits have a $130 copay, which is waived if admitted within 24 hours, and urgently needed services require a $50 copay, both with no coinsurance. This plan also features robust supplemental benefits, including no copay for routine eye exams, eyewear coverage up to a $200 annual limit, and preventive dental care with no copay up to a $1,500 limit. Specialist visits, physical therapy, and routine hearing exams require a $50 copay, while home health and home infusion services are covered with no copay. Additionally, members can access select over-the-counter items and laboratory tests with no copay or coinsurance, helping to further reduce out-of-pocket healthcare expenses.
Inpatient Hospital See details
Network Health Choice (PPO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization. Acute stays carry a $315 daily copay for days 1 to 7 with no copay thereafter, while psychiatric stays require a $295 daily copay for days 1 to 4 with no copay thereafter; upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Network Health Choice (PPO) offers comprehensive outpatient services with no coinsurance, featuring a $300 copay for outpatient hospital and observation services and a $200 copay for ambulatory surgical center visits. Outpatient substance abuse sessions require a $50 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Network Health Choice (PPO) with a $50.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are offered by Network Health Choice (PPO), featuring a $275 copay and no coinsurance for ground and air ambulance services, which require prior authorization. Routine transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
Network Health Choice (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $50 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, but worldwide emergency transportation is not covered.
Primary Care See details
Network Health Choice (PPO) covers primary care physician services with no copay and no coinsurance, and telehealth benefits are available with a $0 to $50 copay and no coinsurance. Specialist visits, physical and occupational therapies, mental health, psychiatric, and opioid treatment services require a $50 copay and no coinsurance, while podiatry services are not covered. Chiropractic services are partially covered with a $15 copay and no coinsurance, but routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by Network Health Choice (PPO) with no copay and no coinsurance for annual physicals, kidney disease education, and other screenings. Additional preventive services are partially covered, providing a memory fitness benefit but excluding health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, home/bathroom safety modifications, and counseling.
Hearing Services See details
Network Health Choice (PPO) partially covers hearing services with no deductible, offering annual routine exams and fittings for a $50 copay and no coinsurance. Prescription hearing aids are covered with a copay ranging from $495.00 to $1,695.00 and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision services are partially covered under Network Health Choice (PPO) with no deductibles or coinsurance, offering one routine eye exam annually with no copay, while other covered exams have a $50 copay up to a $40 yearly limit. Eyewear is covered with no copay or coinsurance up to a $200 annual limit for contacts, eyeglasses, and upgrades, though other eye exam services, individual eyeglass lenses, and individual eyeglass frames are not covered.
Dental Services See details
Dental Services are partially covered by Network Health Choice (PPO), with orthodontics not covered. Medicare-covered dental services require a $50 copay and no coinsurance, while preventive services have no copay and no coinsurance up to a $1,500 annual limit, and comprehensive services require no copay and a 50% coinsurance.
Home Infusion bundled Services See details
Network Health Choice (PPO) covers home infusion bundled services with no copay and no coinsurance, although prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Network Health Choice (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Network Health Choice (PPO) covers medical equipment with no copay and 0% to 20% coinsurance for durable medical equipment and prosthetics. This benefit is partially covered because diabetic supplies are not covered, though diabetic therapeutic shoes and inserts are covered with a $10 copay and no coinsurance.
Diagnostic and Radiological Services See details
Network Health Choice (PPO) covers diagnostic and radiological services with prior authorization required for both. Diagnostic services feature no coinsurance, offering lab services with no copay and diagnostic tests with a $40 to $90 copay. Radiological services require a $90 copay for diagnostic radiology and outpatient X-rays (which also require coinsurance), and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home health services are covered by Network Health Choice (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Network Health Choice (PPO) offers cardiac rehabilitation services with no coinsurance, and while some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered and carry a $15 copay.
Skilled Nursing Facility (SNF) See details
Network Health Choice (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and days 46 through 100, a $218 copay per day for days 21 through 45, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Network Health Choice (PPO), which offers over-the-counter (OTC) items and select lab tests (lipid profile, fasting blood sugar, and CBC) with no copay and no coinsurance. However, acupuncture and meal benefits are not covered.
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