Individual Plan Details

Prestige Bronze 50 HDHP + Dental + Vision

This plan is designed for an individual who wants to offset their medical expenses with a health savings plan (HSA). An HSA can be combined with this plan, as displayed here. The Prestige Bronze 50 HDHP has the lowest deductible of all the Network Health Bronze level plans. Once you’ve met your deductible, you are responsbile for 50 percent coinsurance on covered in-network visits. 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 Bronze 50 HDHP Plan Highlights

DEDUCTIBLE

Individual

$3,500

Family

$7,000

COINSURANCE

 

50%

OUT-OF-
POCKET LIMIT

Individual

$6,900

Family

$13,800

BENEFITS

Preventive Care

$0

Routine Vision Exam

$0

Annual Dental Exam

$0

Personal Doctor Visit

50% after deductible

Virtual Visit

0% after deductible

Specialist Visit

50% after deductible

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 50 HDHP 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% after deductible

Tier 2 Generics

30% after deductible

Tier 3 Brand Drugs

40% after deductible

Tier 4 Non-Preferred Brand Drugs

50% 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.