Common Ground Healthcare Cooperative

CGHC Gold $0 Ded - Envision Network

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500.00 Family: $17000 Per Person: $8500

Office Visit

Primary Doctor	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $55.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process. $15 Copay for Preferred Insulin for Gold and Silver plans.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Covered: Covered Benefit Explanation: Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process
Specialty Drugs	CoPay: Not Applicable CoInsurance: 30.00% Covered: Covered Benefit Explanation: Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered