CGHC HSA Silver $3200 – Envision Network – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$3,200 per person $3,200 per person
Out-of-pocket max	$8,000 per person $16,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$15 copay after deductible
Specialist visit	$35 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	15% coinsurance after deductible
Emergency room	15% coinsurance after deductible
Ambulance	15% coinsurance after deductible
Hospital stay (facility)	15% coinsurance after deductible
Hospital stay (physician)	15% coinsurance after deductible
Outpatient procedure (facility)	15% coinsurance after deductible
Outpatient procedure (physician)	15% coinsurance after deductible
Physical rehabilitation	15% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	15% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay after deductible
Brand	15% coinsurance after deductible
Non-preferred Brand	15% coinsurance after deductible
Specialty	15% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	15% coinsurance after deductible
Imaging (CT/PET/MRI)	15% coinsurance after deductible
Blood work	15% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$15 copay after deductible
Psychiatric hospital stay	15% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_HSA_Silver_3200-Envision__SBC.pdf
Drug and medication plan formulary	https://commongroundhealthcare.org/formulary/
Search doctor list	https://commongroundhealthcare.org/find-a-doctor/