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CGHC Gold $1800 - Envision Network (Vision Exam + Allergy Test)
Health Insurance Plan Details (2025 Plan)
by Common Ground Healthcare Cooperative
Monthly Premium
EPO
$ubsidy
Gold
- Deductible
- $1,800 /yr
- Max Out-of-Pocket
- $6,600 /yr
Details
| Deductible (per individual) | $1,800 /yr |
| Deductible (per family) | $3,600 /yr |
| Max Out-of-Pocket (per individual) | $6,600 /yr |
| Max Out-of-Pocket (per family) | $13,200 /yr |
| Drug Deductible (per individual) | |
| Drug Deductible (per family) | |
| Drug Max Out-of-Pocket (per individual) | |
| Drug Max Out-of-Pocket (per family) | |
| Plan Type | EPO |
| Includes Child Dental? | No |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $25 Copay |
| Specialist Visit | $50 Copay |
| Emergency Room | $300 Copay |
| Inpatient Facility | 20.00% Coinsurance after deductible |
| Inpatient Physician | 20.00% Coinsurance after deductible |
| Generic Drugs | $10 Copay |
| Preferred Brand Drugs | $50 Copay |
| Non-preferred Brand Drugs | $100 Copay after deductible |
| Specialty Drugs | 30.00% Coinsurance after deductible |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | n/a |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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