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Individual Plan Highlights

Prestige Silver

This plan is good for an individual who wants a reasonable deductible along with low copayments for common medical services, but no dental, vision or fitness benefits. As with all Network Health plans, preventive services are $0. The below chart details the benefits of this plan.

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Prestige Silver Plan Highlights

DEDUCTIBLE

Individual

$5,800

Family

$11,600

COINSURANCE

 

40%

OUT-OF-
POCKET LIMIT

Individual

$8,900

Family

$17,800

BENEFITS

Preventive Care

$0

Routine Vision Exam

Not covered

Annual Dental Exam

Not covered

Personal Doctor Visit

$40 per visit

Virtual Visit

$0 per visit

Specialist Visit

$80 per visit 

Chiropractic

40% after deductible

Hospital Stay

40% after deductible

Emergency Room

40% after deductible

X-ray and Diagnostic Imaging

40% 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 Silver 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

$20

Tier 2 Preferred Brand Drugs

$40

Tier 3 Non-Preferred Brand Drugs

$80 after deductible 

Tier 4 Preferred Specialty Drugs

$350 after deductible

Tier 5 Non-Preferred Specialty Drugs

$500 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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