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Individual and Family Plans

Prestige Bronze Essential

This plan is designed for individuals looking for low monthly premiums and quality coverage. Prestige Bronze Essential provides preventive services for $0. With this plan, your first three primary care doctor visits are $0 and any additional visits are $30. The below chart details the benefits of this plan.

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Prestige Bronze Essential Plan Highlights

DEDUCTIBLE

Individual

$7,000

Family

$14,000

COINSURANCE

 

50%

OUT-OF-
POCKET LIMIT

Individual

$7,900

Family

$15,800

BENEFITS

Preventive Care

$0

Primary Care Doctor Visit

$0 for first three visits, then $30 per visit

Specialist Visit

$80 per visit 

Chiropractic

50% after deductible

Hospital Stay

50% after deductible

Emergency Room

$500 per visit after deductible

X-ray and Diagnostic Imaging

$60 per visit after deductible

Laboratory Outpatient Services

$30 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

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

$2 (Tier 1)

Generics

$20 (Tier 2)

Preferred Brand Drugs

$80 after deductible
(Tier 3)

Non-Preferred Brand Drugs

35% after deductible
(Tier 4)

Preferred Specialty Drugs

35% after deductible
(Tier 5)

Non-Preferred Specialty Drugs

50% after deductible
(Tier 6)


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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.