CGHC Silver $600 CSR 87% – Envision Network – EPO

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	$3,150 per person $6,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	$70 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	25% coinsurance after deductible
Emergency room	$100 copay
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	20% 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	$30 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-Envision_SBC.pdf
Drug and medication plan formulary	https://commongroundhealthcare.org/formulary/
Search doctor list	https://commongroundhealthcare.org/find-a-doctor/