Network Health Plan

Prestige Gold

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual Visits $0, Telehealth same cost share of in person visit
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual Visits $0, Telehealth same cost share of in person visit

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $15.00 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: $250.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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: 25.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $45.00 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: 25.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 25.00% 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

Covered: Not Covered