Common Ground Healthcare Cooperative

CGHC HSA Bronze $7000 Deductible

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,000 Family: $14,000 Per Person: $7,000
Medical Out-of-Pocket Maximum	Individual: Not Applicable Family: not applicable Per Person: not applicable
Drug Out-of-Pocket Maximum	Individual: Not Applicable Family: not applicable Per Person: not applicable
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000 Family: $14,000 Per Person: $7,000

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible 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
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible 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: Not Applicable CoInsurance: 0.00% Coinsurance after deductible 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: 0.00% Coinsurance after deductible 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: 0.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

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

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: Not Applicable Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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