CGHC Silver $4000 - Envision Network

Health Insurance Plan Details (2024 Plan)

by Common Ground Healthcare Cooperative

Monthly Premium

EPO
$ubsidy
Silver
Deductible
$4,000 /yr
Max Out-of-Pocket
$9,450 /yr

Details

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

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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