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Individual Plan Highlights

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

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. In addition, you get a $0 annual vision exam and dental exam for each covered member. 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

$9,100

Family

$18,200

BENEFITS

Preventive Care

$0

Routine Vision Exam

$0

Annual Dental Exam

$0

Personal Doctor Visit

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

Virtual Visit

$0 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

  

 

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
antidiabetics, statins,
and RAS antagonists)

$0

Tier 1 Generics

$15

Tier 2 Preferred Brand Drugs

$60

Tier 3 Non-Preferred Brand Drugs

50% after deductible

Tier 4 Preferred Specialty Drugs

40% after deductible

Tier 5 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.