Chorus Silver Copay

14630WI0010011
Silver
EPO

Chorus Silver Copay is a Silver EPO plan by Chorus Community Health Plans.

IMPORTANT: You are viewing the 2024 version of Chorus Silver Copay 14630WI0010011. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Chorus Silver Copay is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Chorus Silver Copay 14630WI0010011.
Insurer: Chorus Community Health Plans
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 14630WI0010011

Cost-Sharing Overview

Chorus Silver Copay 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 Chorus Silver Copay?

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

Chorus Silver Copay offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Depression, Diabetes, Pregnancy
Notice Pregnancy: No
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 Chorus Silver Copay 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
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency
National Network: No

Additional Benefits and Cost-Sharing

Chorus Silver Copay 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
$40.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$130.00 Not ApplicableNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Hospice Services
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 Not Applicable$45.00 Not Applicable
Home Health Care Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%60.0 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
$1,500.00 Not Applicable$1,500.00 Not Applicable
Emergency Transportation/Ambulance
Covered
$130.00 Not Applicable$130.00 Not Applicable
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
$1250.00 Copay per Day Not ApplicableNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
$1250.00 Copay per Day Not ApplicableNot Applicable 100.00%30.0 Days per Stay
Prenatal and Postnatal Care
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
$1,250.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
$1250.00 Copay per Day Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
$1250.00 Copay per Day Not ApplicableNot Applicable 100.00%
Generic Drugs
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$140.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00% CCHP contracts with a program to reduce the cost of specialty drugs on select plans. Members who opt out of the program may have a different costs than what is displayed.
Outpatient Rehabilitation Services
Covered
$80.00 Not ApplicableNot Applicable 100.00% Rehabilitative services must be short term.
Habilitation Services
Covered
$80.00 Not ApplicableNot Applicable 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
$40.00 Not ApplicableNot Applicable 100.00% Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.
Durable Medical Equipment
Covered
$130.00 Not ApplicableNot Applicable 100.00%
Hearing Aids
Covered
$130.00 Not ApplicableNot Applicable 100.00%1.0 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
$1,000.00 Not ApplicableNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No ChargeNot Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No ChargeNot Applicable 100.00%
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$80.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Rehabilitative services must be short term.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$80.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$50.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$140.00 Not ApplicableNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
$130.00 Not ApplicableNot Applicable 100.00%
Accidental Dental
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Dialysis
Covered
$100.00 Not ApplicableNot Applicable 100.00%
Allergy Testing
Not Covered
Chemotherapy
Covered
$130.00 Not ApplicableNot Applicable 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
$130.00 Not ApplicableNot Applicable 100.00%
Diabetes Education
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
$130.00 Not ApplicableNot Applicable 100.00%
Infusion Therapy
Covered
$130.00 Not ApplicableNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
$130.00 Not ApplicableNot Applicable 100.00%
Gender Affirming Care
Covered
$130.00 Not ApplicableNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Chorus Silver Copay 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 Chorus Silver Copay 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 Chorus Silver Copay?

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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