Network Health Prime (MSA)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: No

Diagnostic procedures/lab services/imaging

• Lab services
  • $0 copay after you pay your deductible
• Diagnostic tests and procedures
  • $0 copay after you pay your deductible
• Diagnostic radiology services (e.g., MRI)
  • $0 copay after you pay your deductible
• Outpatient x-rays
  • $0 copay after you pay your deductible

Doctor visits

• Primary
  • $0 copay after you pay your deductible
• Specialist
  • $0 copay after you pay your deductible

Emergency care/Urgent care

• Urgent care
  • $0 copay after you pay your deductible
• Emergency
  • $0 copay after you pay your deductible

Foot care (podiatry services)

• Routine foot care
  • Not covered
• Foot exams and treatment
  • $0 copay after you pay your deductible

Ground ambulance

• • $0 copay after you pay your deductible

Health plan deductible

• • $4,600 annual deductible

Hearing

• Fitting/evaluation
  • Not covered
• Hearing aids – inner ear
  • Not covered
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • $0 copay after you pay your deductible
• Hearing aids – outer ear
  • Not covered
• Hearing aids – over the ear
  • Not covered

Inpatient hospital coverage

• • $0 copay after you pay your deductible

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • Not Applicable

Medical equipment/supplies

• Diabetes supplies
  • $0 copay after you pay your deductible
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • $0 copay after you pay your deductible
• Prosthetics (e.g., braces, artificial limbs)
  • $0 copay after you pay your deductible

Medicare Part B drugs

• Chemotherapy
  • $0 copay after you pay your deductible
• Other Part B drugs
  • $0 copay after you pay your deductible

Mental health services

• Outpatient group therapy visit with a psychiatrist
  • $0 copay after you pay your deductible
• Inpatient hospital – psychiatric
  • $0 copay after you pay your deductible
• Outpatient individual therapy visit with a psychiatrist
  • $0 copay after you pay your deductible
• Outpatient group therapy visit
  • $0 copay after you pay your deductible
• Outpatient individual therapy visit
  • $0 copay after you pay your deductible

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • $0 copay after you pay your deductible

Preventive care

• • $0 copay

Rehabilitation services

• Physical therapy and speech and language therapy visit
  • $0 copay after you pay your deductible
• Occupational therapy visit
  • $0 copay after you pay your deductible

Skilled Nursing Facility

• • $0 copay after you pay your deductible

Transportation

• • Not covered

Vision

• Contact lenses
  • Not covered
• Eyeglasses (frames and lenses)
  • Not covered
• Upgrades
  • Not covered
• Eyeglass frames
  • Not covered
• Eyeglass lenses
  • Not covered
• Other
  • Not covered
• Routine eye exam
  • Not covered

Wellness programs (e.g., fitness, nursing hotline)

• • Not covered

OSB – 2025 – 1_Dental

Comprehensive Dental

• Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
  • Monthly Premium: $45.00
  • Max Coverage: $1000.00
  • Coverage Periodicity: Every year
  • Deductible Services: 16c1: Restorative Services, 16c2: Endodontics, 16c3: Periodontics, 16c4: Prosthodontics, removable, 16c5: Maxillofacial Prosthetics, 16c7: Prosthodontics, fixed, 16c8: Oral and Maxillofacial Surgery, 16c10: Adjunctive General Services
  • Deductible: $100.00

Diagnostic and Preventive Dental

• Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services
  • Monthly Premium: $45.00
  • Max Coverage: $1000.00
  • Coverage Periodicity: Every year