Network Health Plan

Signature Prestige Bronze $0 Deductible + Dental + Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,100.00 Family: $18200 Per Person: $9100

Office Visit

Primary Doctor	CoPay: $55.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual Visits $0, Telehealth same cost share of in person visit
Specialist	CoPay: $150.00 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: $160.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% 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% 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: $1500.00 Copay per Day CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $2,000.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $75.00 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: $1,500.00 CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
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