2019 Assure plan brochure

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

4

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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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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

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“

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

10

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ASSURE PLAN BENEFIT

DESIGNS

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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

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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

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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