CGHC Copay Gold $0 Ded – Envision Network – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $75 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $8,500 per person $17,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $500 copay |
| Ambulance | 20% coinsurance |
| Hospital stay (facility) | 20% coinsurance |
| Hospital stay (physician) | 20% coinsurance |
| Outpatient procedure (facility) | 20% coinsurance |
| Outpatient procedure (physician) | 20% coinsurance |
| Physical rehabilitation | $70 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $55 copay |
| Non-preferred Brand | 30% coinsurance |
| Specialty | 30% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $60 copay |
| Imaging (CT/PET/MRI) | 20% coinsurance |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | 20% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_Copay_Gold_0Ded-Envision_SBC.pdf |
| Drug and medication plan formulary | https://commongroundhealthcare.org/formulary/ |
| Search doctor list | https://commongroundhealthcare.org/find-a-doctor/ |
