Page 78 - Cover Letter & Evaluation for Patricia Letizia

10/11/2018 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 53151
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 5933054208
and more coverage and star ratings.
Password Date: 10/11/2018
Important Coverage Information

You are now viewing 2019 plan data. View 2018 plan data.
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A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Network Health Medicare 1570 Midway Place, P.O. Box 120 Overall Star Rating: [?] Enrollment begins
Menasha, WI 54952 October 15, 2018
Go (PPO)
(H5215-009-0) Members: 4 out of 5 stars
1-800-378-5234
Organization: Network Health Medicare 1-800-947-3529 (TTY/TDD)
Advantage Plans
Non Members:
Plan Type: Local Preferred 1-800-983-7587
Provider Organization 1-800-947-3529 (TTY/TDD)

Benefits Highlights

Monthly health plan premium $0.00

Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $5,900 In and Out-of-network
responsibility (does not include $5,900 In-network
prescription drugs)
Optional supplemental benefits [?] Yes

Additional benefits and/or reduced cost-
sharing for enrollees with certain health In-Network: No
conditions?

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