CGHC Silver $600 CSR 87% ($25 PCP Copay) – Envision Network (Dental/Vision Exam) – EPO
87% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $25 copay
Specialist visit: $55 copay
Urgent care visit: 25% coinsurance after deductible
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $600 per person $600 per person |
| Out-of-pocket max | $3,140 per person $6,280 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $55 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 25% coinsurance after deductible |
| 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 | $5 copay |
| Brand | $50 copay |
| Non-preferred Brand | 25% coinsurance |
| Specialty | 40% coinsurance |
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 | $25 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_600_CSR_87_25PCP-Envision_DentVisExam_SBC.pdf |
| Drug and medication plan formulary | https://commongroundhealthcare.org/formulary/ |
| Search doctor list | https://commongroundhealthcare.org/find-a-doctor/ |
