WINNEBAGO CALUMET WASHINGTON OZAUKEE ......WAUKESHA RACINE WASHINGTON OZAUKEE MILWAUKEE KENOSHA...

1570 Midway Pl.Menasha, WI 54952

844-635-1322networkhealth.com/individual

HMO plans underwritten by Network Health Plan. Nondiscrimination - Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Multi-language Interpreter Services - If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 855-275-1400. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 855-275-1400. Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 855-275-1400.1788-02-0919

2020 Prestige Individual and Family Plans

Wisconsin-Based Health Plan844-635-1322 networkhealth.com/individual

Meet Network HealthWe’re a local, Wisconsin-based health insurance company that puts customers first. Co-owned by Froedtert Health and Ministry Health Care, part of Ascension Wisconsin, we understand the importance of quality health care and believe it should be convenient.

Great Coverage Close to HomeWith a Network Health Prestige plan, you have access to a network of high-quality doctors, hospitals, clinics and specialists, so you can get the care you need close to home.

For the most up-to-date provider list or to find a doctor or facility, visit networkhealth.com/find-a-doctor/prestige and type in the Help Me Find field.

The Hometown Advantage

We Speak Your LanguageWhen you call Network Health, we don’t bombard you with health insurance language. We talk like people, not insurance dictionaries. Our plain-language approach—paired with high-rated customer service—provides the ultimate customer experience.

We Live in Your CommunityBeing local allows us to focus on our mission to create healthy and strong Wisconsin communities. At Network Health, our employees strive to provide exceptional service because we know we are helping our neighbors, friends and family.

We Cut Costs, Not CornersOur plans give you access to health care professionals who can answer your questions and connect you with programs to manage your health. If you have a health condition, our nurse care managers or condition managers can help you develop a customized care plan to improve your health and prevent costly complications.

OUTAGAMIE

WINNEBAGOCALUMET

WAUKESHA

RACINE

WASHINGTONWASHINGTON

OZAUKEEOZAUKEE

MILWAUKEEMILWAUKEE

KENOSHA

That’s why we offer a variety of plan options to ensure you have the quality coverage you need and want at an affordable cost. As you compare plans, remember you may qualify for a subsidy from the government, if you purchase your Network Health Prestige plan through the Health Insurance Exchange, also known as the Marketplace, at HealthCare.gov.

All our plans are Health Maintenance Organization (HMO) plans, which means you’ll need to use our high-quality network of doctors, hospitals, clinics and specialists for services to be covered—this includes labs and services your doctor may refer—so you’ll want to ensure all providers are in-network before receiving services.

Check out the chart on the right to learn about Network Health’s Prestige plans, which are all available on the Health Insurance Exchange.

What’s that?Subsidy—Financial help provided by the government to help people afford health insurance. There are two types of subsidies—premium tax credits and cost-sharing reductions. A premium tax credit helps make your monthly premium payments lower. A cost-sharing reduction lowers the amount you pay for health insurance deductibles, copayments and coinsurance. If you qualify for a subsidy, you must obtain coverage through the Marketplace to receive the benefit.

PLAN COMPARISONPrestige Bronze Essential + Dental + Vision + Fitness + 3 Free PCP Visits

Prestige Bronze 20 HDHP + Dental + Vision

Prestige Bronze 0 + Dental + Vision

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

Prestige Silver 20 HDHP + Dental + Vision

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

Prestige Gold 50 + Dental + Vision

Prestige Gold 0 HDHP + Dental + Vision

Monthly Premium $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

DEDUCTIBLEIndividual $7,200 $6,000 $6,700 $3,500 $4,000 $3,500 $1,750 $1,000 $2,800

Family $14,400 $12,000 $13,400 $7,000 $8,000 $7,000 $3,500 $2,000 $5,600

Coinsurance 50% 20% $0 after deductible 50% 40% 20% 20% 50% $0 after deductible

OUT-OF-POCKET LIMIT

Individual $8,150 $6,900 $8,150 $6,900 $8,150 $6,900 $8,150 $4,300 $5,000

Family $16,300 $13,800 $16,300 $13,800 $16,300 $13,800 $16,300 $8,600 $10,000

BENEFITS

Preventive Care $0 $0 $0 $0 $0 $0 $0 $0 $0

Routine Vision Exam $0 $0 $0 $0 $0 $0 $0 $0 $0

Annual Dental Exam $0 $0 $0 $0 $0 $0 $0 $0 $0

Primary Care Doctor Visit

$0 for first three visits, then $40 per visit 20% after deductible $0 after deductible 50% after deductible $0 for first three visits,

then $25 per visit 20% after deductible $0 for first three visits, then $20 per visit 50% after deductible $0 after deductible

Virtual Visit $0 per visit 0% after deductible $0 after deductible 0% after deductible $0 per visit 0% after deductible $0 per visit 0% after deductible $0 after deductible

Specialist Visit $100 per visit 20% after deductible $0 after deductible 50% after deductible $80 per visit 20% after deductible $60 per visit 50% after deductible $0 after deductible

Chiropractic 50% after deductible 20% after deductible $0 after deductible 50% after deductible 40% after deductible 20% after deductible 20% after deductible 50% after deductible $0 after deductible

Hospital Stay 50% after deductible 20% after deductible $0 after deductible 50% after deductible 40% after deductible 20% after deductible 20% after deductible 50% after deductible $0 after deductible

Emergency Room $500 after deductible per visit 20% after deductible $0 after deductible 50% after deductible $500 after deductible

per visit 20% after deductible $350 per visit 50% after deductible $0 after deductible

X-ray and Diagnostic Imaging

$60 after deductibleper visit 20% after deductible $0 after deductible 50% after deductible $60 per visit 20% after deductible $50 per visit 50% after deductible $0 after deductible

PHARMACY BENEFIT COMPARISON

RETAIL30-DAY SUPPLYCost per prescription or refill

Preventive Drugs $0 $0 $0 $0 $0 $0 $0 $0 $0

Tier 1Adherence Generics (limited only to categories of antidiabetics, statins, and RAS antagonists)

$0 $0 after deductible $0 $0 after deductible $0 $0 after deductible $0 $0 $0 after deductible

Tier 2 Generics $20 20% after deductible $20 30% after deductible $20 20% after deductible $15 $15 $0 after deductible

Tier 3 Preferred Brand Drugs $80 after deductible 20% after deductible $70 after deductible 40% after deductible $80 20% after deductible $60 $50 $0 after deductible

Tier 4 Non-Preferred Brand Drugs 35% after deductible 35% after deductible 35% after deductible 50% after deductible 35% after deductible 35% after deductible 35% after deductible 35% after deductible 35% after deductible

Tier 5 Preferred Specialty Drugs 35% after deductible 35% after deductible 35% after deductible 35% after deductible 35% after deductible 35% after deductible 35% after deductible 35% after deductible 35% after deductible

Tier 6 Non-Preferred Specialty Drugs 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible

New for 2020 – Lower Rates, Extra Benefits

Your health insurance needs are unique.

$Typically, as plans go up in metal level (bronze, silver, gold) you’ll get more coverage and pay more for your monthly premium. Your exact monthly premium depends on the financial assistance you may be eligible for through the government. To find out what your premium will be, get a quote at networkhealth.com/individual.

A fitness benefit with a free Fitbit®—upon request— and access to over 350 fitness locations in Wisconsin with Prestige Essential plans

A dental exam, bite-wing x-ray and dental cleaning

$25 per month program for preferred insulin

$0 Virtual doctor visits (for some plans, deductible must be met first)

A Momentum healthy rewards program offers the opportunity to earn $100 in gift cards for completing four tasks essential to your health and wellness

An annual vision exam and discounts on prescription eyewear

Lower rates for all Network Health Prestige plans

$0 adherence generic drugs (for some plans, deductible must be met first)