CGHC Copay Bronze $0 Ded / $2250 Rx Ded – Envision Network (Dental/Vision Exam) – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $100 copay
Urgent care visit: $200 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $200 copay |
| Emergency room | $1,800 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $1500 copay per Day |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $200 copay |
| Outpatient procedure (physician) | $200 copay |
| Physical rehabilitation | $100 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $35 copay |
| Brand | $140 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $150 copay |
| Imaging (CT/PET/MRI) | $1,075 copay |
| Blood work | $75 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | $1500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_Copay_Bronze_0Ded-Envision_DentVisExam_SBC.pdf |
| Drug and medication plan formulary | https://commongroundhealthcare.org/formulary/ |
| Search doctor list | https://commongroundhealthcare.org/find-a-doctor/ |
