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Individual Plan Details

Prestige Silver 20 HDHP + Dental + Vision

This plan offers a deductible and coinsurance midway between the Bronze and Gold HDHP plans. This is the perfect plan for you if you want a reasonable deductible at a lower premium than a gold level plan. Once your deductible has been met, you will be responsible for 20 percent coinsurance on additional in-network medical care you receive. In addition, you get a $0 annual vision exam and dental exam for each covered member. This plan is HSA (Health Savings Account) qualified if a cost-sharing reduction subsidy is not applied. The below chart details the benefits of this plan.

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Prestige Silver 20 HDHP Plan Highlights

DEDUCTIBLE

Individual

$3,500

Family

$7,000

COINSURANCE

 

20%

OUT-OF-
POCKET LIMIT

Individual

$7,000

Family

$14,000

BENEFITS

Preventive Care

$0

Routine Vision Exam

$0

Annual Dental Exam

$0

Personal Doctor Visit

20% after deductible

Virtual Visit

0% after deductible

Specialist Visit

20% after deductible

Chiropractic

20% after deductible

Hospital Stay

20% after deductible

Emergency Room

20% after deductible

X-ray and Diagnostic Imaging

20% after deductible

 

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 20 HDHP 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% after deductible

Tier 2 Generics

20% after deductible

Tier 3 Preferred Brand Drugs

20% 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


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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.