1570 Midway Pl. Menasha, WI 54952 800-276-8004 networkhealth.com/employer/plans/assure
Self-insured plans administered by Network Health Administrative Services, LLC. 2043-01-1018
ASSURE
Level-Funded Plans Enjoy the best of both worlds— the security of a fully insured plan with the advantages of a self-insured plan
Available to employers with 2-100 enrolled employees
Providing a cost-effective, comprehensive health plan for your employees can be a challenge. Network Health is making it easier for employers by offering a hybrid product that combines the benefits of a fully insured and self-insured plan. Our Assure level-funded product includes all the features of our fully insured plans, like health management, a wellness program, network discounts and online tools. By self-funding the plan, we can offer benefit designs comparable to your current plan while avoiding the costly mandates of an ACA plan.
In this book you will find ... What is level-funding? .........................................................................................................................2 How does Assure work?.......................................................................................................................2 Which companies qualify to purchase Assure?.................................................................................3 What are the advantages of Assure?.................................................................................................3 Who’s who?..........................................................................................................................................4 Why choose Network Health?.............................................................................................................5 Practical example.................................................................................................................................6 Assure provider network......................................................................................................................8 Pharmacy benefits and online tools...................................................................................................8 Health management services.............................................................................................................9 Empower wellness program............................................................................................................. 10 Network Health’s Nurse Line........................................................................................................... 10 Assure plan benefit designs............................................................................................................. 11
Looking for more? Contact your agent, broker or consultant to learn more about the Assure plan and to get a quote. Visit networkhealth.com/employer/plans/assure for more details or you can call our sales team at 800-276-8004.
1
WHAT IS LEVEL-FUNDING? Level-funding is a cost-effective health plan funding solution that allows companies to benefit from predictable, set monthly rates similar to a fully insured plan. Instead of monthly premiums, your company will be responsible for a specified level of claim liability. This means each month you will fund this maximum claim liability, thereby eliminating the normal volatility of self-funding. If your company’s claims are less than the amount you’ve funded at the end of the year, you get 50 percent of the funding surplus. Payments are calculated after the 24-month claim liability period has expired (12 months after the end of the policy year). If your claims go over the funded amount, your company is protected by stop-loss coverage. This limits your company’s risk exposure and protects you from catastrophic claims. An advance funding feature allows claims to be paid, even when your funding level is less than claim payments. This feature ensures that you’ll never pay more than your maximum claim funding amount for any month of the year.
HOW DOES ASSURE WORK? Your company funds the account for your Assure plan, while Network Health Administrative Services, LLC, administers the plan. Your monthly funding will consist of the following. •Administrative fee •Stop-loss premium •Claims funding The funding amount will vary based upon the number of employees and/or dependents covered by the plan. Assure is a bundled product that incorporates the features of a fully insured health plan with the opportunity to get money back.
Stop-loss coverage This protects employers by covering the cost of claims that exceed the agreed upon claims funding.
2
networkhealth.com/employer/plans/assure
800-276-8004
WHICH COMPANIES QUALIFY TO PURCHASE ASSURE?
FULLY INSURED
TRADITIONAL SELF-INSURED
To purchase our Assure product, your company must have 2-100 enrolled employees with at least 80 percent of employees located in Network Health’s service area. Assure is an excellent choice for employers looking for an alternative to ACA-compliant health plans.
WHAT ARE THE ADVANTAGES OF ASSURE? u Have the opportunity to earn back 50 percent of surplus claim funds at the end of the policy year. u Your employees can earn up to $225 in rewards for healthy choices with our Empower wellness program. u Eliminate the financial risk and funding fluctuations that you may see with a traditional self-insured plan. u Save on health care costs and put more resources back into your business. u Experience a bundled product like a fully insured plan and the financial advantages of a self-insured plan.
Expected claims and administrative fee
Claims ? funding
Administrative fee
Stop-loss Claims funding is variable and it can change
? based on the health care needs of the group.
Potential to get 50 percent of unused claims funds back
Claims funding
Stop-loss ACA-compliant health plans ACA-compliant health plans are individual or small group plans that include the required essential health benefits. The Network Health ACA-compliant plans are labeled by metal level (Bronze, Silver, Gold and Platinum).
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Administrative fee LEVEL-FUNDED
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3
WHO’S WHO? Plan Sponsor - Employer and stop-loss policy-holder Plan Participant - Employee Stop-Loss Insurance Carrier - Network Health Insurance Corporation (NHIC) Third Party Administrator (TPA) - Network Health Administrative Services, LLC (NHAS) NHAS administers your plan on your behalf, which includes the following. u Paying claims and maintaining proper funds on deposit for claims payment u Preparing claims reports or other data necessary for the plan and/or the stop-loss insurer (NHIC) u Providing plan information for filing government required reports except for filing and payment of PCORI (Patient-Centered Outcomes Research Institute) fees u Billing and collecting administrative fees and stop-loss premium for the plan u Handling appeals u NHAS prepares the plan document on behalf of the plan sponsor/employer u NHAS will secure stop-loss coverage through NHIC. There is an integrated approach between NHAS, the administrator and NHIC, the stop-loss carrier. u COBRA Administration services provided by Employee Benefits Corporation
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networkhealth.com/employer/plans/assure
800-276-8004
WHY CHOOSE NETWORK HEALTH?
We’re a locally owned, Wisconsin-based company that’s been around for more than 35 years. We partner with and live in the communities we serve.
We keep things running smoothly We deliver quick and accurate plan administration and our customer service is rated higher than Wisconsin and national averages in several categories.
We speak in plain language We know health insurance can be intimidating. That’s why we give you straight answers that are easy to understand.
We understand the importance of quality health care Co-owned by Froedtert Health and Ministry Health Care, a part of Ascension, we’re able to offer access to a large network of high-quality providers. Assure plan participants have access to deep discounts through participating providers in the Assure network.
Focused on the individual We believe in partnering with our members for better health. Our Assure plan gives your employees access to nurse care managers to manage health conditions.
800-276-8004
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5
PRACTICAL EXAMPLE Pie in the Sky Pizzeria is a family-owned and operated pizza restaurant with multiple locations in northeast Wisconsin and has become a favorite among locals and tourists. Since the company’s opening in 2011, Pie in the Sky Pizzeria has grown from ten to 30 full-time employees. Tony, the owner, is currently offering a health plan to his employees that’s compliant with the Affordable Care Act. Because the costs are really cutting into his bottom line, he decided to start searching for an alternative health plan. Pie in the Sky Pizzeria has a total of 30 full-time employees and 25 dependents participating in the health plan. All of the employees live in Winnebago, Outagamie and Waupaca counties. Let’s take a look at how the Network Health Assure plan works and why it’s a perfect fit for Tony and his employees.
6
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800-276-8004
Annual medical claims total..................................$20,000 Annual claims difference............$13,190
Pie in the Sky Pizzeria’s 50 percent refund............ $6,595 Network Health Administrative Services (Third Party Administrator) issues the refund.
Annual claims funding ................$33,190 Annual medical claims total..................................$42,000
Annual claims difference....................... -$8,810 Stop-loss insurance covers the claims difference.
Pie in the Sky Pizzeria does not have to pay the difference.
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PIE IN THE SKY PIZZERIA EMPLOYEE BREAKDOWN
BEST CASE WORST CASE
PIE IN THE SKY PIZZERIA GROUP BREAKDOWN
Annual claims funding ................$33,190
Joseph is an employee at Pie in the Sky Pizzeria and is a participant of the Assure plan. This year he incurred $13,000 in claims due to his cardiac disease. The graphic below shows how this affects Pie in the Sky Pizzeria’s annual claims funding.
$3,000 balance covered by stop-loss $10,000 specific deductible per employee
$13,000 claims for cardiac disease
networkhealth.com/employer/plans/assure
7
WHAT’S THE PROVIDER NETWORK FOR ASSURE? To search for providers in each network, use our Find a Doctor search at networkhealth.com. Employees can log in to the member portal at login.networkhealth.com to view plan-specific information and select a primary care physician.
PHARMACY BENEFITS AND ONLINE TOOLS
Through our partnership with CVS/caremark™, you’ll have access to an extensive pharmacy network, so your employees will have the convenience of a pharmacy near their home or work. CVS/caremark™ works to provide innovative and accessible prescription benefits while keeping costs low. The pharmacy network for Assure includes the following pharmacies.
u CVS u Costco u Shopko u Walmart u Other independent pharmacies and clinical locations along with a prescription drug mail-order program Here are some of the online tools that are included. u CVS/Caremark™ mobile app to refill prescriptions on-the-go u View Prescription History and Personalized Drug Information to find information about your medications u Ask-a-pharmacist messaging to get confidential and reliable answers to your prescription and over-the-counter drug questions CVS/caremark’s customer service center is open 24 hours a day, seven days a week to answer questions about prescription drug coverage.
8
networkhealth.com/employer/plans/assure
800-276-8004
HEALTH MANAGEMENT SERVICES Complex Care Management
We offer care management services to help people with high-risk conditions. We identify candidates through claims, health assessment data, doctor referrals and self-referrals. Our experienced nurse care managers work with people to develop customized care plans and help them navigate the health care world. Care managers can help with the following. u Coordinating care with providers u Explaining medical instructions u Providing guidance on care and how to avoid problems u Making follow-up calls so members know exactly what to do, who to see and where to go for the treatment they need u Assisting with access to care u Informing people about the signs that indicate their condition is worsening, so they know when to call the doctor
Condition Management
Network Health’s condition management programs empower people with chronic health conditions to take charge of their health and better manage symptoms. Our team of registered nurses provide health coaching, education and other resources to help. Here is what they do. u Identify health goals and find tools to achieve them u Find educational self-management workshops and community events to teach skills needed to manage a condition u Promote healthy lifestyle behaviors such as exercise and eating right u Provide resources on how to manage symptoms u Support communication with doctors
u Chronic obstructive pulmonary disease (COPD) u Asthma u Diabetes u Heart failure u Heart disease
Our nurses are known to visit members in the hospital. It’s that kind of personal attention that sets Network Health apart. 800-276-8004
networkhealth.com/employer/plans/assure
“
I love feeling like I’m actually making a difference.
“
We offer condition management programs for these conditions.
Yvonne Morrow, RN, oncology care manager at Network Health
9
EMPOWER WELLNESS PROGRAM
Empower is an innovative program that encourages participants and their covered spouses to make healthy decisions. Empower rewards participants for meeting health and fitness goals, and gives them access to the tools they need to support their goals. Participants can earn points with cash value up to $225 redeemable toward a variety of rewards. Another perk of the Empower program is that participants also receive a free Fitbit® Inspire pedometer to help monitor activity.
Everyone who registers for the member portal can request a FREE pedometer (a $6995 value). Go to login.networkhealth.com to register. Select My Wellness, click on Order Pedometer & Allow Access. Participants can also upgrade to a different Fitbit device at a reduced cost. (One pedometer per lifetime.)
NETWORK HEALTH’S NURSE LINE The Network Health Nurse Line is available 24 hours a day, seven days a week, 365 days a year. It’s available for need-it-now situations and it’s a great resource for any of the following. u Symptoms like a sore throat, muscle pain or fever u Help figuring out where to go for non-emergency care u Advice or additional information on general health issues u Questions, information or instructions for current or newly prescribed medications To access the Network Health Nurse Line, call 888-879-8960.
VIRTUAL VISITS
Empower
17
Your covered employees have 24/7/365 access to board-certified doctors from their phone, secure video or a mobile App. It’s virtual care for many non-emergency conditions and behavioral health.
A GREAT INCENTIVE FOR HEALTHY LIVING
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networkhealth.com/employer/plans/assure
800-276-8004
ASSURE PLAN BENEFIT
DESIGNS
800-276-8004
networkhealth.com/employer/plans/assure
11
EPO NON-HSA PLANS 912
Deductible
Coinsurance
Out-of-Pocket Maximum
PLAN #
PLAN NAME
Single
Family
What Participants Pay
Single
Family
AE5
LF_E1000 COCHOICE_20
$1,000
$2,000
20%
$3,000
$6,000
AE6
LF_E1500 COCHOICE_20
$1,500
$3,000
20%
$3,500
$7,000
AE7
LF_E2000 COCHOICE_20
$2,000
$4,000
20%
$4,000
$8,000
AE8
LF_E2500 COCHOICE_20
$2,500
$5,000
20%
$4,500
$9,000
AE9
LF_E3000 COCHOICE_20
$3,000
$6,000
20%
$5,000
$10,000
AE10
LF_E4000 COCHOICE_20
$4,000
$8,000
20%
$6,000
$12,000
AE11
LF_E5000 COCHOICE_20
$5,000
$10,000
20%
$6,850
$13,700
Office Visit Copayment PCP
Specialist
Emergency Room
Urgent Care
MDLIVE® Virtual Visits
$30 per visit
$60 per visit
$250 per visit
$150 per visit
$10 per visit
D = Deductible Only D/C = Deductible and Coinsurance These summaries are intended to highlight and give a general description of the benefits available. For a complete description of benefits, limitations and exclusions, please refer to the Summary of Participant Responsibility Tables.
networkhealth.com/employer/plans/assure
800-276-8004
Retail 30-day supply
Mail order 90-day supply
Retail 30-day supply
Mail order 90-day supply
All plans with 20% coinsurance
Generics
$20 per prescription or refill
Preferred brand drugs
$40 per prescription or refill
Non-preferred prescription drugs
$60 per prescription or refill
Preferred specialty drugs
25% after deductible
Non-preferred specialty drugs Generics
40% after deductible $55 per prescription or refill mail order
Preferred brand drugs
$105 per prescription or refill mail order
Non-preferred prescription drugs
$180 per prescription or refill mail order
Preferred specialty drugs
No mail order
Non-preferred specialty drugs
No mail order
Buy-Up Pharmacy Benefits
All plans with 20% coinsurance
Generics
$10 per prescription or refill
Preferred brand drugs
$25 per prescription or refill
Non-preferred prescription drugs
$50 per prescription or refill
Preferred specialty drugs
25% after deductible
Non-preferred specialty drugs
40% after deductible
Generics
$25 per prescription or refill mail order
Preferred brand drugs
$60 per prescription or refill mail order
Non-preferred prescription drugs
$150 per prescription or refill mail order
Preferred specialty drugs
No mail order
Non-preferred specialty drugs
No mail order
800-276-8004
EPO NON-HSA PHARMACY
Standard Pharmacy Benefits
networkhealth.com/employer/plans/assure
13
EPO HSA PLANS 914
Out-of-Pocket Maximum
PLAN #
PLAN NAME
Single
Family
What Participants Pay
Single
Family
PCP
Specialist
Emergency Room
Urgent Care
MDLIVE@ Virtual Visits
AEH1
LF_HSAE1500_0
$1,500
$3,000
0%
$1,500
$3,000
D
D
D
D
D
AEH2
LF_HSAE1500_20
$1,500
$3,000
20%
$2,000
$4,000
D/C
D/C
D/C
D/C
D/C
AEH3
LF_HSAE2000_0
$2,000
$4,000
0%
$2,000
$4,000
D
D
D
D
D
AEH4
LF_HSAE2000_20
$2,000
$4,000
20%
$2,500
$5,000
D/C
D/C
D/C
D/C
D/C
Deductible
Coinsurance
Office Visit
AEH5
LF_HSAE2500_0
$2,500
$5,000
0%
$2,500
$5,000
D
D
D
D
D
AEH6
LF_HSAE2500_20
$2,500
$5,000
20%
$3,000
$6,000
D/C
D/C
D/C
D/C
D/C
AEH7
LF_HSAE3000_0
$3,000
$6,000
0%
$3,000
$6,000
D
D
D
D
D
AEH8
LF_HSAE3000_20
$3,000
$6,000
20%
$5,000
$10,000
D/C
D/C
D/C
D/C
D/C
AEH9
LF_HSAE3500_0
$3,500
$7,000
0%
$3,500
$7,000
D
D
D
D
D
AEH10
LF_HSAE3500_20
$3,500
$7,000
20%
$5,500
$11,000
D/C
D/C
D/C
D/C
D/C
AEH11
LF_HSAE4000_0
$4,000
$8,000
0%
$4,000
$8,000
D
D
D
D
D
AEH12
LF_HSAE4000_20
$4,000
$8,000
20%
$6,000
$12,000
D/C
D/C
D/C
D/C
D/C
AEH13
LF_HSAE5000_0
$5,000
$10,000
0%
$5,000
$10,000
D
D
D
D
D
AEH14
LF_HSAE5000_20
$5,000
$10,000
20%
$6,550
$13,100
D/C
D/C
D/C
D/C
D/C
AEH15
LF_HSAE6500_0
$6,500
$13,000
0%
$6,500
$13,000
D
D
D
D
D
D = Deductible Only D/C = Deductible and Coinsurance These summaries are intended to highlight and give a general description of the benefits available. For a complete description of benefits, limitations and exclusions, please refer to the Summary of Participant Responsibility Tables.
networkhealth.com/employer/plans/assure
800-276-8004
Retail 30-day supply
Preferred brand drugs
Deductible
$40 per prescription or refill after deductible
Non-preferred prescription drugs
Deductible
$60 per prescription or refill after deductible
Preferred specialty drugs
Deductible
25% after deductible
Non-preferred specialty drugs
Deductible
Generics
Deductible
40% after deductible $55 prescription or refill mail order after deductible
Mail order 90-day supply
Preferred brand drugs
Deductible
$105 prescription or refill mail order after deductible
Non-preferred prescription drugs
Deductible
$180 prescription or refill mail order after deductible
Preferred specialty drugs
No mail order
No mail order
Non-preferred specialty drugs
No mail order
No mail order
Buy-Up Pharmacy Benefits
All plans with 20% coinsurance
Generics
All plans with 0% coinsurance Deductible
Preferred brand drugs
Deductible
Retail 30-day supply
$25 per prescription or refill after deductible
Non-preferred prescription drugs
Deductible
$50 per prescription or refill after deductible
Preferred specialty drugs
Deductible
25% after deductible
Non-preferred specialty drugs
Deductible
40% after deductible
Generics
Deductible
Preferred brand drugs
Deductible
$25 per prescription or refill mail order after deductible $60 per prescription or refill mail order after deductible
Mail order 90-day supply
Non-preferred prescription drugs Preferred specialty drugs
Deductible No mail order
$150 per prescription or refill mail order after deductible No mail order
Non-preferred specialty drugs
No mail order
No mail order
800-276-8004
$20 per prescription or refill after deductible
$10 per prescription or refill after deductible
networkhealth.com/employer/plans/assure
EPO HSA PHARMACY
All plans with 20% coinsurance
Generics
All plans with 0% coinsurance Deductible
Standard Pharmacy Benefits
15
POS NON-HSA PLANS 916
Deductible In-Network
Coinsurance
Out-of-Network Family
In-Network
PLAN # AP5
PLAN NAME LF_P1000 COCHOICE_20
Single
Family
Single
$1,000
$2,000
$2,000
$4,000
20%
AP6
LF_P1500 COCHOICE_20
$1,500
$3 ,000
$3 ,000
$6,000
AP7
LF_P2000 COCHOICE_20
$2,000
$4,000
$4,000
AP8
LF_P2500 COCHOICE_20
$2,500
$5,000
AP9
LF_P3000 COCHOICE_20
$3,000
AP10
LF_P4000 COCHOICE_20
AP11
LF_P5000 COCHOICE_20
Out-ofNetwork
What Participants Pay
Out-of-Pocket Maximum In-Network
Out-of-Network
Office Visit In-Network
Out-ofNetwork
PCP
In-Network
Out-ofNetwork
Single
Family
Single
Family
40%
$3 ,000
$6,000
$6,000
$12,000
D/C
D/C
20%
40%
$3,500
$7,000
$7,000
$14,000
D/C
D/C
$8,000
20%
40%
$4,000
$8,000
$8,000
$16,000
D/C
D/C
$5,000
$10,000
20%
40%
$4,500
$9,000
$9,000
$18,000
$6,000
$6,000
$12,000
20%
40%
$5,000
$10,000
$10,000
$20,000
D/C
D/C
$4,000
$8,000
$8,000
$16,000
20%
40%
$6,000
$12,000
$12,000
$24,000
D/C
D/C
$5,000
$10,000
$10,000
$20,000
20%
40%
$6,850
$13,700
$13,700
$27,400
D/C
D/C
$30 per visit
Specialist
D/C
$60 per visit
D/C
D = Deductible Only D/C = Deductible and Coinsurance These summaries are intended to highlight and give a general description of the benefits available. For a complete description of benefits, limitations and exclusions, please refer to the Summary of Participant Responsibility Tables.
Emergency/Urgent Care In-Network
Out-of-Network
Emergency Room
$250 per visit
$250 per visit
Urgent Care
$150 per visit
40% after deductible
networkhealth.com/employer/plans/assure
Virtual Visits $10 per visit for all POS Non-HSA Plan. Benefits are only available through the Network Health virtual visit provider network.
800-276-8004
POS NON-HSA PHARMACY
All plans with 20% coinsurance Standard Pharmacy Benefits
Retail 30-day supply
Mail order 90-day supply
Retail 30-day supply
Mail order 90-day supply
In-Network
Out-of-Network
Generics
$20 per prescription or refill
Not Covered
Preferred brand drugs
$40 per prescription or refill
Not Covered
Non-preferred prescription drugs
$60 per prescription or refill
Not Covered
Preferred specialty drugs
25% after deductible
Not Covered
Non-preferred specialty drugs
40% after deductible
Not Covered
Generics
$55 per prescription or refill mail order
Not Covered
Preferred brand drugs
$105 per prescription or refill mail order Not Covered
Non-preferred drugs
$180 per prescription or refill mail order Not Covered
Preferred specialty drugs
No mail order
Not Covered
Non-preferred specialty drugs
No mail order
Not Covered
Buy-Up Pharmacy Benefits
All plans with 20% coinsurance In-Network
Out-of-Network
Generics
$10 per prescription or refill
Not Covered
Preferred brand drugs
$25 per prescription or refill
Not Covered
Non-preferred prescription drugs
$50 per prescription or refill
Not Covered
Preferred specialty drugs
25% after deductible
Not Covered
Non-preferred specialty drugs
40% after deductible
Not Covered
Generics
$25 per prescription or refill mail order $60 per prescription or refill mail order
Not Covered
Preferred brand drugs Non-preferred prescription drugs
$150 per prescription or refill mail order
Not Covered
Preferred specialty drugs
No mail order
Not Covered
Non-preferred specialty drugs
No mail order
Not Covered
800-276-8004
Not Covered
networkhealth.com/employer/plans/assure
17
Deductible
POS HSA PLANS
In-Network
918
PLAN # PLAN NAME AHP1 LF_HSAP1500_0
Coinsurance
Out-of-Network
In-Network Out-of-Network
Out-of-Pocket Maximum In-Network
Out-of-Network
Office Visit In-Network
Out-of-Network
Single
Family
Single
Family
What Participants Pay
Single
Family
Single
Family
PCP
Specialist
PCP
Specialist
$1,500
$3,000
$2,500
$5,000
0%
$1,500
$3,000
$4,000
$8,000
D
D
D/C
D/C
20%
AHP2
LF_HSAP1500_20
$1,500
$3,000
$3,000
$6,000
20%
40%
$2,000
$4,000
$6,000
$12,000
D/C
D/C
D/C
D/C
AHP3
LF_HSAP2000_0
$2,000
$4,000
$3,000
$6,000
0%
20%
$2,000
$4,000
$5,000
$10,000
D
D
D/C
D/C
AHP4
LF_HSAP2000_20
$2,000
$4,000
$4,000
$8,000
20%
40%
$2,500
$5,000
$7,000
$14,000
D/C
D/C
D/C
D/C
AHP5
LF_HSAP2500_0
$2,500
$5,000
$3,500
$7,000
0%
20%
$2,500
$5,000
$6,000
$12,000
D
D
D/C
D/C
AHP6
LF_HSAP2500_20
$2,500
$5,000
$5,000
$10,000
20%
40%
$3,000
$6,000
$8,000
$16,000
D/C
D/C
D/C
D/C
AHP7
LF_HSAP3000_0
$3,000
$6,000
$4,000
$8,000
0%
20%
$3,000
$6,000
$8,000
$16,000
D
D
D/C
D/C
AHP8
LF_HSAP3000_20
$3,000
$6,000
$6,000
$12,000
20%
40%
$5,000
$10,000
$9,000
$18,000
D/C
D/C
D/C
D/C
AHP9
LF_HSAP3500_0
$3,500
$7,000
$4,500
$9,000
0%
20%
$3,500
$7,000
$9,000
$18,000
D
D
D/C
D/C
AHP10
LF_HSAP3500_20
$3,500
$7,000
$7,000
$14,000
20%
40%
$5,500
$11,000
$11,000
$22,000
D/C
D/C
D/C
D/C
AHP11
LF_HSAP4000_0
$4,000
$8,000
$5,000
$10,000
0%
20%
$4,000
$8,000
$10,000
$20,000
D
D
D/C
D/C
AHP12
LF_HSAP4000_20
$4,000
$8,000
$8,000
$16,000
20%
40%
$6,000
$12,000
$12,000
$24,000
D/C
D/C
D/C
D/C
AHP13
LF_HSAP5000_0
$5,000
$10,000
$6,000
$12,000
0%
20%
$5,000
$10,000
$13,100
$26,200
D
D
D/C
D/C
AHP14
LF_HSAP5000_20
$5,000
$10,000
$9,000
$18,000
20%
40%
$6,550
$13,100
$13,000
$26,000
D/C
D/C
D/C
D/C
AHP15
LF_HSAP6500_0
$6,500
$13,000
$7,500
$15,000
0%
20%
$6,500
$13,000
$14,000
$28,000
D
D
D/C
D/C
D = Deductible Only D/C = Deductible and Coinsurance These summaries are intended to highlight and give a general description of the benefits available. For a complete description of benefits, limitations and exclusions, please refer to the Summary of Participant Responsibility Tables.
Emergency/Urgent Care
Virtual Visits
0% Coinsurance
20% Coinsurance
In-Network
In-Network
Emergency Room
Deductible
Urgent Care
D
Out-of-Network
Subject to deductible and coinsurance Out-of-Network
Deductible/Coinsurance D/C
networkhealth.com/employer/plans/assure
D/C
D/C
(Example: Sue has a virtual visit with an online doctor. The cost is $55. She has already met her deductible. The $55 is now subject to the coinsurance of her plan. If Sue had not yet met her deductible, she would pay $55 for the virtual visit and it would be applied toward her deductible.)
800-276-8004
Retail 30-day supply
Mail order 90-day supply
Retail 30-day supply
Mail order 90-day supply
800-276-8004
All plans with 20% coinsurance
In-Network
Out-of-Network
In-Network
Out-of-Network
Generics
Deductible
Not Covered
$20 per prescription or refill after deductible
Not Covered
Preferred brand drugs
Deductible
Not Covered
$40 per prescription or refill after deductible
Not Covered
Non-preferred prescription drugs
Deductible
Not Covered
$60 per prescription or refill after deductible
Not Covered
Preferred specialty drugs
Deductible
Not Covered
25% after deductible
Not Covered
Non-preferred specialty drugs
Not Covered Not Covered
40% after deductible $55 per prescription or refill mail order after deductible
Not Covered
Generics
Deductible Deductible
Preferred brand drugs
Deductible
Not Covered
$105 per prescription or refill mail order after deductible
Not Covered
Non-preferred prescription drugs
Deductible
Not Covered
$180 per prescription or refill mail order after deductible
Not Covered
Preferred specialty drugs
No mail order
Not Covered
No mail order
Not Covered
Non-preferred specialty drugs
No mail order
Not Covered
No mail order
Not Covered
Buy-Up Pharmacy Benefits
In-Network
Out-of-Network
In-Network
Out-of-Network
Generics
Deductible
Not Covered
$10 per prescription or refill after deductible
Not Covered
All plans with 0% coinsurance
Not Covered
All plans with 20% coinsurance
Preferred brand drugs
Deductible
Not Covered
$25 per prescription or refill after deductible
Not Covered
Non-preferred prescription drugs
Deductible
Not Covered
$50 per prescription or refill after deductible
Not Covered
Preferred specialty drugs
Deductible
Not Covered
25% after deductible
Not Covered
Non-preferred specialty drugs
Deductible
Not Covered
40% after deductible
Not Covered
$25 per prescription or refill mail order after deductible $60 per prescription or refill mail order after deductible
Not Covered
Generics
Deductible
Not Covered
Preferred brand drugs
Deductible
Not Covered
Non-preferred prescription drugs
Deductible
Not Covered
Not Covered
Preferred specialty drugs
No mail order
Not Covered
$150 per prescription or refill mail order after deductible Not Covered No mail order Not Covered
Non-preferred specialty drugs
No mail order
Not Covered
No mail order
Not Covered
networkhealth.com/employer/plans/assure
POS HSA PHARMACY
All plans with 0% coinsurance Standard Pharmacy Benefits
19
Looking for more? Contact your agent, broker or consultant to learn more about the Assure plan and to get a quote. Visit networkhealth.com/employer/plans/assure for more details or you can also reach our sales team at 800-276-8004.
1570 Midway Pl. Menasha, WI 54952 800-276-8004 networkhealth.com/employer/plans/assure
Self-insured plans administered by Network Health Administrative Services, LLC. 2043-02-0419
ASSURE
Level-Funded Plans Enjoy the best of both worlds— the security of a fully insured plan with the advantages of a self-insured plan
Available to employers with 2-100 enrolled employees