Network Health Plan

Prestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,750.00 Family: $15,500 Per Person: $7,750
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $55.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $110.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Adherence Generics are available at $0 copay or 0% coinsurance after deductible for certain categories of medications.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The coinsurance for Non-preferred specialty drugs is 10% higher than Preferred Specialty drugs. There is No Cost for covered Specialty Drugs for the Native American/Alaskan Limited and Zero Cost share plans.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Urgent Care Outside the Service Area is only covered when furnished by an Emergency room or Hospital-based Urgent Care Facility.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: 1 Exam per year

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Benefit Explanation: One exam, cleaning, and X-ray per year
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: One exam, cleaning, and X-ray per year

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