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Prestige Bronze

81413WI0480001
Bronze
HMO

Prestige Bronze is a Bronze HMO plan by Network Health.

IMPORTANT: You are viewing the 2023 version of Prestige Bronze 81413WI0480001. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Prestige Bronze is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Prestige Bronze 81413WI0480001.
Insurer: Network Health
Network Type: HMO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 81413WI0480001

Cost-Sharing Overview

Prestige Bronze offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Prestige Bronze?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Prestige Bronze offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Prestige Bronze covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care
National Network: No

Additional Benefits and Cost-Sharing

Prestige Bronze includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
No Charge after deductible 100.00%
Specialist Visit
Covered
No Charge after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
No Charge after deductible No Charge after deductible Urgent Care Outside the Service Area is only covered when furnished by an Emergency room or Hospital-based Urgent Care Facility.
Home Health Care Services
Covered
No Charge after deductible 100.00%60 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.
Emergency Room Services
Covered
No Charge after deductible No Charge after deductible
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%30 Days per Stay
Prenatal and Postnatal Care
Covered
No Charge after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%
Generic Drugs
Covered
No Charge after deductible 100.00% Adherence Generics are available at $0 copay or 0% coinsurance after deductible for certain categories of medications.
Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Specialty Drugs
Covered
No Charge after deductible 100.00%
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00% Rehabilitative services must be short term. Limited to 20 visits per benefit year for each: Occupational, Speech, Physical and Pulmonary therapy. Cardiac Rehabilitation Therapy is limited to 36 visits per benefit year.
Habilitation Services
Covered
No Charge after deductible 100.00% Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Limited to 20 visits per benefit year for each: Occupational, Speech, and Physical therapy.
Chiropractic Care
Covered
No Charge after deductible 100.00% Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.
Durable Medical Equipment
Covered
No Charge after deductible 100.00% Will cover 20 DME devices/items per year, whether rented or purchased in accordance with the requirements set out in the Policy.
Hearing Aids
Covered
No Charge after deductible 100.00% Covers the cost of basic hearing aids limited to one hearing aid per ear, including repair or replacement, once every three years.
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge 100.00% 1 Exam per year
Eye Glasses for Children
Covered
No Charge 100.00% 1 item per year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Year Rehabilitative services must be short term. Limited to 20 visits per benefit year for each: Speech therapy.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Year Limited to 20 visits per benefit year for each: Occupational and Physical therapy.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00% A lower copay/coinsurance applies to certain labs for condition management of chronic diseases
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
No Charge after deductible 100.00%
Accidental Dental
Covered
No Charge after deductible 100.00%
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Covered
No Charge after deductible 100.00%
Chemotherapy
Covered
No Charge after deductible 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
No Charge after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00% Covers up to 10 prosthetic devices that replace a limb or a body part each Benefit Year.
Infusion Therapy
Covered
No Charge after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00% Coverage for diagnostic procedures and non-surgical treatment limited to 10 services and/or devices per Benefit Year.
Nutritional Counseling
Reconstructive Surgery
Covered
No Charge after deductible 100.00%
Gender Affirming Care
Prescription Drugs Other
Covered
No Charge after deductible 100.00% Formulary Tier 5: Non-preferred specialty drugs

Free Preventive Services

There is no copayment or coinsurance for any of the following Prestige Bronze preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Prestige Bronze including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Prestige Bronze?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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