Individual Plan Highlights

Prestige Silver Essential

This plan is good for an individual who wants a reasonable deductible along with low copayments for common medical services. You'll receive your first three primary care doctor visits for $0 and any additional visits are $25. As with all Network Health plans, preventive services are $0. The below chart details the benefits of this plan.

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Prestige Silver Essential Plan Highlights

DEDUCTIBLE

Individual

$4,000

Family

$8,000

COINSURANCE

 

40%

OUT-OF-
POCKET LIMIT

Individual

$7,900

Family

$15,800

BENEFITS

Preventive Care

$0

Primary Care Doctor Visit

$0 for first three visits, then $25 per visit

Specialist Visit

$80 per visit 

Chiropractic

40% after deductible

Hospital Stay

40% after deductible

Emergency Room

$500 per visit after deductible

X-ray and Diagnostic Imaging

$60 per visit

Laboratory Outpatient Services

$30 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 Silver 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

$20
(Tier 2)

Preferred Brand Drugs

$80
(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.