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Individual and Family Plans

Prestige Bronze Plus

The Prestige Bronze Plus plan is good for an individual who wants an affordable monthly premium and quality coverage, without dental, vision or fitness benefits. There are separate copayments and coinsurance for prescription drugs. The below chart details the benefits of this plan.

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Prestige Bronze Plus Plan Highlights

DEDUCTIBLE

Individual

$7,500

Family

$15,000

COINSURANCE

 

50% after deductible

OUT-OF-
POCKET LIMIT

Individual

$9,000

Family

$18,000

BENEFITS

Preventive Care

$0

Routine Vision Exam

Not coverd

Annual Dental Exam

Not covered

Personal Doctor Visit

$50 copayment
per visit

Virtual Visit

$0 copayment
per visit

Specialist Visit

$100 copayment
per visit

Chiropractic

50% after deductible

Hospital Stay

50% after deductible

Emergency Room

50% after deductible

X-ray and Diagnostic Imaging

50% 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 Bronze Plus 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

$25

Tier 2 Preferred Brand Drugs

$50 after deductible

Tier 3 Non-Preferred Brand Drugs

$100 after deductible

Tier 4 Preferred Specialty Drugs

$500 after deductible

Tier 5 Non-Preferred Specialty Drugs

$750 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.

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