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 two dental exams for each covered member. The below chart details the benefits of this plan.
This plan is also available without dental and vision benefits.
Prestige Gold Essential Plan Highlights |
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DEDUCTIBLE |
Individual |
$1,750 |
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Family |
$3,500 |
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COINSURANCE |
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20% |
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OUT-OF- |
Individual |
$8,950 |
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Family |
$17,900 |
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BENEFITS |
Preventive Care |
$0 |
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Routine Vision Exam |
$0 |
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Annual Dental Exam |
Reimbursement |
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Personal Doctor Visit |
$0 for first three visits per family member, then $20 per visit |
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Virtual Visit |
$0 per visit |
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Specialist Visit |
$60 per visit |
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Chiropractic |
20% after deductible |
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Hospital Stay |
20% after deductible |
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Emergency Room |
$350 per visit |
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X-ray and Diagnostic Imaging |
$50 per visit |
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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 |
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Retail |
Preventive Drugs |
$0 |
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Tier 1 Generic and Adherence Generic Drugs Adherence Generics are limited to specific medications to treat certain conditions and are designated in the comprehensive drug list with the label “$0” and are available at no cost, subject to applicable deductible |
$15 |
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Tier 2 Preferred Brand Drugs |
$60 |
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Tier 3 Non-Preferred Brand Drugs |
50% after deductible |
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Tier 4 Preferred Specialty Drugs |
40% after deductible |
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Tier 5 Non-Preferred Specialty Drugs |
50% after deductible |
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