Network Health Plan

Prestige Silver Essential + Dental + Vision + 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: $4,600.00 Family: $9200 Per Person: $4600
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,100.00 Family: $18200 Per Person: $9100

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual Visits $0, Telehealth same cost share of in person visit
Specialist	CoPay: $80.00 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: $80.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $20.00 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: 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: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% 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 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: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% 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: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Two exams, cleanings, and one bitewing X-ray per year
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Two exams and cleanings and one bitewing x-ray per year