Network Health Premier (PPO) Plan Details for Sheboygan County, WI
CMS rated this Network Health Medicare Advantage Plans plan (H5215-006-0) 5.0 stars (Excellent), making it a top-rated plan from this insurance company.
Network Health Premier (PPO) is a Medicare Advantage plan without a prescription drug plan. The 2025 enrollment period begins Oct. 15.
See more Medicare Advantage Plans in Sheboygan County, Wisconsin.
2025 Network Health Premier Cost and Coverage Notification
The 2025 cost and coverage information for Network Health Premier will not be available until early October. We'll notify you as soon as it is available from CMS.
Sign-Up for 2025 Medicare Plan Notification. The 2025 Annual Enrollment Period begins October 15.
Network Health Premier Basic Details
Plan Basics | |
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Plan ID: | H5215-006-0 |
Plan Type: | Local PPO |
Plan Year: | 2024 |
Premium: | $95.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $3,400/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Not Included |
Rx Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Sheboygan County, WI |
Insured By: | Network Health Medicare Advantage Plans |
Summary of Benefits |
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Network Health Medicare Advantage Plans Out-of-Pocket Costs
This Network Health Medicare Advantage Plans Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H5215-006-0.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $10 Copay |
Specialist: | $20 Copay Prior Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $20 Copay Prior Authorization Required |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay Prior Authorization Required |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $110 Copay |
Urgent care: | $20 Copay |
Ground ambulance: | $0 |
Inpatient hospital coverage: | $75.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital coverage: | $0 |
Skilled Nursing Facility: | |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $0 |
Outpatient group therapy visit with a psychiatrist: | $0 |
Inpatient hospital - psychiatric: | |
Outpatient group therapy visit: | $0 |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $20 Copay Prior Authorization Required |
Occupational therapy visit: | $20 Copay Prior Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment (e.g., wheelchairs, oxygen): | $0 |
Prosthetics (e.g., braces, artificial limbs): | $0 |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $0 |
Lab services: | $0 |
Outpatient x-rays: | $0 |
Diagnostic tests and procedures: | $0 |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Network Health Premier Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Network Health Medicare Advantage Plans includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | Covered Limits may apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | Non Specified |
Eyeglasses (frames and lenses) (In-Network) | Not Covered |
Routine eye exam (In-Network) | $10 Copay |
Contact lenses (In-Network) | Not Covered |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) and drug plans (Part D) in several major categories using a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join Network Health Premier.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- Network Health Go
- Network Health Plus
- Network Health Armor
- Network Health Anywhere
- Network Health Premier
- Network Health Choice
- Network Health PlusRx
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Network Health Medicare Advantage Plans
Plan Website: | https://networkhealth.com/ |
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Formulary Information: | https://networkhealth.com/find-a-pharmacy.html |
Pharmacy Information: | Network Health Medicare Advantage Plans Pharmacy Page |
Prospective Members: | (800)983-7587 |
TTY Users: | (800)947-3529 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Network Health Medicare Advantage Plans, https://networkhealth.com/, Last Accessed February 20, 2024
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You in Different Formats", Last Accessed February 19, 2024
- Medicare.gov, "Is Your Test, Item, or Service Covered?", Last Accessed June 3, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.