Network PlatinumPlus Pharmacy

The Network PlatinumPlus Pharmacy Plan offers considerable savings on prescription drug costs and includes over 50,000 network pharmacies. On top of that, you'll enjoy a $0 co–pay for a number of in-network services, generous coverage for preventive care services and more! You'll even receive in-network benefits when you travel out of state. And the maximum you will pay out-of-pocket for Medicare-covered services both in and out-of-network will be $2,000 annually excluding prescription drug costs. For more information on the benefits of the Network PlatinumPlus Pharmacy Plan, read the explanations below or go to the Summary of Benefits for details and coverage comparison charts.

Coverage Details for Network PlatinumPlus Pharmacy:
Medicare prescription drug coverage
Network PlatinumPlus Pharmacy is pleased to offer a prescription drug benefit with NO deductible. You begin using your benefit with your first prescription. Plus, it includes coverage for the "gap" — so you're covered before your total yearly drug costs reach out-of-pocket maximum. The plan uses a formulary that meets the Medicare guidelines for comprehensive coverage and offers a preferred list of drugs that can result in lower co-pays for our members. Network Health Plan has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

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Travel benefits
With Network PlatinumPlus Pharmacy, you’ll receive the right care at the right time from the right provider no matter where you are. So you can travel in comfort knowing that your health care is there when you need it. If you’re traveling outside the state of Wisconsin and need medical care, please show your Network PlatinumPlus Pharmacy member ID card and you’ll receive the same level of benefits as you would from Network Providers at home.

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Inpatient hospitalization
You shouldn’t have to suffer a financial hardship when a serious illness results in a hospital stay. That’s why, with Network PlatinumPlus Pharmacy, you have no co-pay for a Medicare-eligible hospitalization at the in-network hospitals. At out-of-network hospitals, you pay $75 each day for days 1 – 7 unless you are admitted within one day of an emergency room visit at that hospital for the same condition you were treated for during your emergency room visit. There is an out-of-pocket maximum of $1,000 if you are hospitalized at a non-network hospital for a non-emergency reason.

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Diabetes self-monitoring training and medical nutrition therapy
You pay no co-payment for in-network Medicare-covered Diabetes self-monitoring training and nutrition therapy. However, a separate physician office visit co-payment may apply for these services.

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Diagnostic tests, X-rays and lab services
A separate physician office visit co-payment may apply for the following services:

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Emergency and urgently needed care
Network PlatinumPlus Pharmacy covers you for emergency and urgently needed care anywhere in the world. You never pay more than $50 for each Medicare-covered emergency room visit when services are received in the United States. If you are admitted to that hospital for the same condition within one day of the emergency room visit, you do NOT pay the $50 for the emergency room visit. With worldwide out-of-network emergency services, Network PlatinumPlus Pharmacy will pay 75% of your medical charges up to a $100,000 limit each year.

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Pre-authorization
Some of the covered services listed in the Summary of Benefits Chart are covered only if your Network PlatinumPlus Pharmacy plan doctor or other plan provider gets “prior authorization” (approval in advance) from Network Health Insurance Corporation. In these cases, you need to have prior authorization when you see plan providers. Covered services that need prior authorization will be stated in the Summary of Benefits Chart. You will pay more if you receive these services from a non-plan physician or provider.

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• Routine Physical Exams (limited to 1 exam every year)
• Bone Mass Measurements
• Colorectal Screening Exams
• Immunizations
• Mammograms
• Pap Smears/Pelvic Exams
• Prostate Cancer Screenings
• You pay $10 out-of-network for preventive services, including routine physical exams except there is no co-pay for Medicare-covered pneumonia and flu vaccines.

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Outpatient surgery
In-network, you pay a $0 co-pay for each visit to an outpatient hospital facility or ambulatory surgical center. Out-of-network, you pay $75 for each visit to an outpatient hospital facility or ambulatory surgical center.

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Health and wellness education – after-hours information
Network PlatinumPlus Pharmacy offers a variety of Health Education and Disease Management services. For additional information on the services and the benefits available to you, contact the Network PlatinumPlus Pharmacy Customer Service Department at 1–800–378–5234, Monday, Wednesday, Thursday and Friday, 8 a.m. to 5 p.m., and Tuesday, 8 a.m. to 4 p.m.  For the hearing impaired, call TTY/TDD 1–800–947–3529.

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We want you to be healthy – and happy
If at any time you’re unsatisfied with the care you receive from the Network PlatinumPlus Pharmacy plan, you have the right to make a complaint through our Grievance and Appeals Procedures.

Additionally, if you have problems getting the prescription drugs you think we should provide, there are actions you can take to initiate a Coverage Determination or Exceptions Process, and request payment.

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Enroll NOW
As long as you have Medicare Part A or Medicare Part B, you can enroll in the Network PlatinumPlus Pharmacy plan online right now by clicking here. Once completed and submitted, your enrollment form will be reviewed and your coverage will be effective January 1, 2008 for those who enroll before December 31, 2007. After that, enrollees' coverage will be effective the first of the month following their enrollment submission.

Your Premiums
When you join the Network PlatinumPlus Pharmacy plan, your monthly plan premium will be $58. Members must continue to pay monthly Medicare Part B premiums.

Note: Once you enroll in the Network PlatinumPlus Pharmacy plan, it is important to notify your provider of your plan change prior to receiving services.  If your provider accepts the terms and conditions of Medicare, they will accept the terms and conditions of the Network PlatinumPlus Pharmacy plan.  If they do not accept the terms and conditions of Medicare, their costs may be higher, which means you will have to pay more.