CGHC Copay Gold $0 Ded - Envision Network

Health Insurance Plan Details (2024 Plan)

by Common Ground Healthcare Cooperative

Monthly Premium

EPO
$ubsidy
Gold
Deductible
$0 /yr
Max Out-of-Pocket
$8,500 /yr

Details

Deductible (per individual) $0 /yr
Deductible (per family) $0 /yr
Max Out-of-Pocket (per individual) $8,500 /yr
Max Out-of-Pocket (per family) $17,000 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type EPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $35 Copay
Specialist Visit $75 Copay
Emergency Room $500 Copay
Inpatient Facility 20% Coinsurance
Inpatient Physician 20% Coinsurance
Drug Costs
Generic Drugs $20 Copay
Preferred Brand Drugs $55 Copay
Non-preferred Brand Drugs 30% Coinsurance
Specialty Drugs 30% Coinsurance

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* 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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