CGHC Gold $3000 – Envision Network – EPO

Network type: EPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $75 copay

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Description

Health Care Plan Details

Network type EPO
Deductible $3,000 per person $3,000 per person
Out-of-pocket max $9,300 per person $18,600 per family
Metal tier Gold

Visit Copay

Primary care visit $20 copay
Specialist visit $50 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $75 copay
Emergency room $300 copay
Ambulance 20% coinsurance after deductible
Hospital stay (facility) 20% coinsurance after deductible
Hospital stay (physician) 20% coinsurance after deductible
Outpatient procedure (facility) 20% coinsurance after deductible
Outpatient procedure (physician) 20% coinsurance after deductible
Physical rehabilitation 20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $10 copay
Brand $50 copay
Non-preferred Brand $100 copay after deductible
Specialty 30% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 20% coinsurance after deductible
Imaging (CT/PET/MRI) 20% coinsurance after deductible
Blood work 20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $20 copay
Psychiatric hospital stay 20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_Gold_3000-Envision_SBC.pdf
Drug and medication plan formulary https://commongroundhealthcare.org/formulary/
Search doctor list https://commongroundhealthcare.org/find-a-doctor/