CGHC Silver $150 CSR 94% – Envision Network (Vision Exam) – EPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$150 per person $150 per person
Out-of-pocket max	$2,500 per person $5,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	No charge
Specialist visit	$10 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$30 copay
Emergency room	10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge
Brand	$25 copay
Non-preferred Brand	10% coinsurance after deductible
Specialty	30% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	No charge
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_Silver_150_CSR_94-Envision_VisExam_SBC.pdf
Drug and medication plan formulary	https://commongroundhealthcare.org/formulary/
Search doctor list	https://commongroundhealthcare.org/find-a-doctor/