CGHC Silver $4000 – Envision Network – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $4,000 per person $4,000 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | 25% coinsurance after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | 25% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $75 copay |
| Non-preferred Brand | 25% coinsurance after deductible |
| Specialty | 30% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | 25% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_Silver_4000-Envision_SBC.pdf |
| Drug and medication plan formulary | https://commongroundhealthcare.org/formulary/ |
| Search doctor list | https://commongroundhealthcare.org/find-a-doctor/ |
