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Individual Plan Highlights

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

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. 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 Silver Essential Plan Highlights

DEDUCTIBLE

Individual

$4,000

Family

$8,000

COINSURANCE

 

40%

OUT-OF-
POCKET LIMIT

Individual

$8,150

Family

$16,300

BENEFITS

Preventive Care

$0

Routine Vision Exam

$0

Annual Dental Exam

$0

Personal Doctor Visit

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

Virtual Visit

$0 per visit

Specialist Visit

$80 per visit 

Chiropractic

40% after deductible

Hospital Stay

40% after deductible

Emergency Room

$500 after deductible per visit

X-ray and Diagnostic Imaging

$60 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

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

$0

Tier 2 Generics

$20

Tier 3 Brand Drugs

$80

Tier 4 Non-Preferred Brand Drugs

35% after deductible 

Tier 5 Preferred Specialty Drugs

35% 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.