Individual Plan Highlights

Prestige Gold Essential

This plan offers a low deductible and low copayments for common medical services. This plan is designed for an individual who wants a low deductible but is comfortable with a higher out-of-pocket limit. Your first three primary care doctor visits are $0 and just $20 per visit after that. The below chart details the benefits of this plan.

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Prestige Gold Essential Plan Highlights

DEDUCTIBLE

Individual

$1,750

Family

$3,500

COINSURANCE

 

20%

OUT-OF-
POCKET
LIMIT

Individual

$7,900

Family

$15,800

BENEFITS

Preventive Care

$0

Primary Care Doctor Visit

$0 for first three visits, then $20 per visit

Specialist Visit

$60 per visit 

Chiropractic

20% after deductible

Hospital Stay

20% after deductible

Emergency Room

$350 per visit

X-ray and Diagnostic Imaging

$50 per visit

Laboratory Outpatient Services

$25 per visit

  

 

Prescription drug coverage 

All Network Health’s Prestige plans have built-in pharmacy benefits. See the chart below for prescription drug coverage information.

Prestige Gold Essential Pharmacy Benefit Highlights

Retail
30-Day
supply
Cost per
prescription
or refill

Preventive Drugs

$0

Adherence Generics (limited only to categories of select antidiabetics, statins and RAS antagonists)

$2 (Tier 1)

Generics

$15 (Tier 2)

Preferred Brand Drugs

$60 (Tier 3)

Non-Preferred Brand Drugs

35% after deductible (Tier 4)

Preferred Specialty Drugs

35% after deductible (Tier 5)

Non-Preferred Specialty Drugs

50% after deductible (Tier 6)


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.