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Individual and Family Plans

Prestige Bronze

The Prestige Bronze plan is good for an individual who wants a low monthly premium and quality coverage, without dental, vision or fitness benefits. You will pay $0 for most medical services once your deductible is met. There are separate copayments and coinsurance for prescription drugs. The below chart details the benefits of this plan.

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Prestige Bronze Plan Highlights

DEDUCTIBLE

Individual

$9,100

Family

$18,200

COINSURANCE

 

0% after deductible

OUT-OF-
POCKET LIMIT

Individual

$9,100

Family

$18,200

BENEFITS

Preventive Care

$0

Routine Vision Exam

Not covered

Annual Dental Exam

Not covered

Personal Doctor Visit

0% after deductible

Virtual Visit

$0 per visit

Specialist Visit

0% after deductible

Chiropractic

0% after deductible

Hospital Stay

0% after deductible

Emergency Room

0% after deductible

X-ray and Diagnostic Imaging

0% 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 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% after deductible

Tier 1 Generics

0% after deductible

Tier 2 Preferred Brand Drugs

0% after deductible

Tier 3 Non-Preferred Brand Drugs

0% after deductible

Tier 4 Preferred Specialty Drugs

0% after deductible

Tier 5 Non-Preferred Specialty Drugs

0% 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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