CGHC Bronze $6000 – Envision Network – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$6,000 per person $6,000 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Bronze

Visit Copay

Primary care visit	$35 copay after deductible
Specialist visit	40% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	40% coinsurance after deductible
Emergency room	$1500 copay after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$25 copay
Brand	40% coinsurance after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$35 copay after deductible
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_Bronze_6000-Envision_SBC.pdf
Drug and medication plan formulary	https://commongroundhealthcare.org/formulary/
Search doctor list	https://commongroundhealthcare.org/find-a-doctor/