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Individual Plan Details

Prestige Gold

This plan is ideal if you or your family will be using medical services often, but do not wish to have dental, vision or fitness benefits. Prestige Gold offers broad coverage and you will pay 25% for most services once you meet your deductible. The below chart details the benefits of this plan.

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Prestige Gold Plan Highlights

DEDUCTIBLE

Individual

$2,000

Family

$4,000

COINSURANCE

 

25%

OUT-OF-
POCKET LIMIT

Individual

$8,700

Family

$17,400

BENEFITS

Preventive Care

$0

Routine Vision Exam

Not covered

Annual Dental Exam

Not covered

Personal Doctor Visit

$30 per visit

Virtual Visit

$0 per visit

Specialist Visit

$60 after deductible

Chiropractic

25% after deductible

Hospital Stay

25% after deductible

Emergency Room

25% after deductible

X-ray and Diagnostic Imaging

25% 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 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

$15

Tier 2 Preferred Brand Drugs

$30

Tier 3 Non-Preferred Brand Drugs

$60

Tier 4 Preferred Specialty Drugs

$250

Tier 5 Non-Preferred Specialty Drugs

$400


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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