Individual Plan Details

Prestige Gold 50 + Dental + Vision

This plan offers quality coverage with the lowest deductible of all our plans. It also has the lowest out-of-pocket maximum and you'll be responsible for 50 percent coinsurance on covered-in network services once the deductible has been met. In addition, you get a $0 annual vision exam and dental exam for each covered member. This plan is ideal for a person who is comfortable paying a higher monthly premium and receiving lower medical bills throughout the year. The below chart details the benefits of this plan.

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Prestige Gold 50 Plan Highlights

DEDUCTIBLE

Individual

$1,000

Family

$2,000

COINSURANCE

 

50%

OUT-OF-
POCKET LIMIT

Individual

$4,300

Family

$8,600

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 Gold 50 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

Tier 2 Generics

$15

Tier 3 Brand Drugs

$50

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.