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Individual and Family Plans

Prestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

This plan is designed for individuals looking for low monthly premiums and quality coverage. Prestige Bronze Essential provides preventive services for $0. In addition, you get a $0 annual vision exam and dental exam for each covered member. This plan also includes a free fitness benefit. The below chart details the benefits of this plan.

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Prestige Bronze Essential Plan Highlights

DEDUCTIBLE

Individual

$7,750

Family

$15,500

COINSURANCE

 

50%

OUT-OF-
POCKET LIMIT

Individual

$8,550

Family

$17,100

BENEFITS

Preventive Care

$0

Routine Vision Exam

$0

Annual Dental Exam

$0

Personal Doctor Visit

$0 for first three visits, then $55 per visit

Virtual Visit

$0 per visit

Specialist Visit

$110 per visit 

Chiropractic

50% after deductible

Hospital Stay

50% after deductible

Emergency Room

$500 after deductible per visit

X-ray and Diagnostic Imaging

$60 after deductible 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 Bronze Essential Pharmacy Benefit Highlights

Retail
30-Day
supply
Cost per

prescription
or refill

Preventive Drugs

$0

Tier 1 Adherence Generics (limited only to categories of select antidiabetics, statins and RAS antagonists)

$0

Tier 2 Generics

$30

Tier 3 Preferred Brand Drugs

$80 after deductible

Tier 4 Non-Preferred Brand Drugs

50% after deductible

Tier 5 Preferred Specialty Drugs

40% after deductible

Tier 6 Non-Preferred Specialty Drugs

50% after deductible


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.