CGHC Silver $4000 - Envision Network

Health Insurance Plan Details (2024 Plan)

SBC doc

doctor lookup

drug list

EPO

Silver

Deductible (per individual)	$4,000 /yr
Deductible (per family)	$8,000 /yr
Max Out-of-Pocket (per individual)	$9,450 /yr
Max Out-of-Pocket (per family)	$18,900 /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	$40 Copay
Specialist Visit	$80 Copay
Emergency Room	25% Coinsurance after deductible
Inpatient Facility	25% Coinsurance after deductible
Inpatient Physician	25% Coinsurance after deductible

Drug Costs
Generic Drugs	$20 Copay
Preferred Brand Drugs	$75 Copay
Non-preferred Brand Drugs	25% Coinsurance after deductible
Specialty Drugs	30% Coinsurance after deductible

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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