Individual Plan Details

Prestige Gold 0 HDHP + Dental + Vision

This plan is ideal if you or your family will be using medical services often. Prestige Gold 0 HDHP offers broad coverage and you will pay $0 for most services once you meet your deductible. In addition, you get a $0 annual vision exam and dental exam for each covered member. Prestige Gold 0 HDHP, as displayed here, is HSA (Health Savings Account) qualified. The below chart details the benefits of this plan.

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Prestige Gold 0 HDHP Plan Highlights

DEDUCTIBLE

Individual

$2,800

Family

$5,600

COINSURANCE

 

$0 after deductible

OUT-OF-
POCKET LIMIT

Individual

$5,000

Family

$10,000

BENEFITS

Preventive Care

$0

Routine Vision Exam

$0

Annual Dental Exam

$0

Personal Doctor Visit

$0 after deductible

Virtual Visit

$0 after deductible

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 Gold 0 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

$0 after deductible

Tier 3 Brand Drugs

$0 after deductible

Tier 4 Non-Preferred Brand Drugs

35% 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.