Network Health PremierRx (PPO) Medicare Advantage Plan H5215-005 • 2026 • Brown County, WI

Network Health PremierRx Overview

Coverage Overview for Network Health PremierRx

This MAPD PPO Medicare Advantage plan includes Medicare Part A and Part B services along with integrated prescription drug coverage. The monthly premium is $226.00, and the plan allows access to Medicare-approved providers, with lower costs when using in-network providers. The annual Part D deductible is $340.00.

Primary care visits have a $10 copay | Out-of-network: $10 copay, and specialist visits come with a $20 copay | Out-of-network: $20 copay. Urgent care services carry a $20 copay, and ground ambulance transportation is $0 copay | Out-of-network: $0 copay, 0% coinsurance. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $3400.00. After this limit is reached, in-network services are fully covered.

This plan is recognized by CMS under Plan ID H5215-005. Cost-sharing details are outlined below.

Out-of-Pocket Costs

Network Health PremierRx has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The table below details the most common in-network out-of-pocket expenses for plan H5215-005.

Certain preventive services are covered 100% by Network Health PremierRx as a Part B benefit.

Prescription Drug Coverage

Network Health PremierRx includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Special Needs Plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $340.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Network Health Medicare Advantage Plans starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, Network Health PremierRx may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

Medicare Plan Star Ratings

Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.