CGHC Silver $5000 Ded / $5000 Rx Ded – Envision Network (Dental/Vision Exam) – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$5,000 per person $5,000 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Silver

Visit Copay

Primary care visit	$70 copay
Specialist visit	$115 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	30% coinsurance after deductible
Emergency room	$250 copay
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	$100 copay
Non-preferred Brand	30% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$70 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.commongroundhealthcare.org/assets/pdf/Plans-and-Benefits/2024/SBC/2024_Silver_5000Ded-Envision_DentVisExam_SBC.pdf
Drug and medication plan formulary	https://commongroundhealthcare.org/formulary/
Search doctor list	https://commongroundhealthcare.org/find-a-doctor/