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CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test)

87416WI0060009
Silver
EPO

CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) is a Silver EPO plan by Common Ground Healthcare Cooperative.

IMPORTANT: You are viewing the 2023 version of CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) 87416WI0060009. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) 87416WI0060009.
Insurer: Common Ground Healthcare Cooperative
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 87416WI0060009

Cost-Sharing Overview

CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for CGHC Silver $4000 - Envision Network (Vision Exam + Allergy Test)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: Yes
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Services Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Services Only
National Network: No

Additional Benefits and Cost-Sharing

CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$50.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Covered
0.00% 100.00%1 Exam(s) per Year
Urgent Care Centers or Facilities
Covered
$100.00 $100.00
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%30 Days per Stay
Prenatal and Postnatal Care
Covered
25.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$50.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$50.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00% Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process
Preferred Brand Drugs
Covered
$75.00 Copay after deductible 100.00% Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process
Non-Preferred Brand Drugs
Covered
25.00% Coinsurance after deductible 100.00% Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process
Specialty Drugs
Covered
30.00% Coinsurance after deductible 100.00% Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 100.00% Rehabilitative services must be short term.
Habilitation Services
Covered
25.00% Coinsurance after deductible 100.00% Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Chiropractic Care
Covered
$50.00 100.00% Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
25.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
$0.00 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
$0.00 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
25.00% Coinsurance after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
25.00% Coinsurance after deductible 100.00%20 Visit(s) per Year Rehabilitative services must be short term.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
25.00% Coinsurance after deductible 100.00%20 Visit(s) per Year Separate limits for OT and PT.
Well Baby Visits and Care
Covered
$0.00 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
25.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00%
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
25.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
25.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00%
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for CGHC Silver $4000 - Envision Network (Vision Exam + Allergy Test)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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