Common Ground Healthcare Cooperative

CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $3,000 Family: $6,000 Per Person: $3,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,000 Family: $12,000 Per Person: $6,000

Office Visit

Primary Doctor	CoPay: $15.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $30.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 20.00% 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: 20.00% 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: $15.00 Copay after deductible 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: 20.00% 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: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% 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: No Charge Covered: Covered Limit Quantity: 2 Limit Unit : Exam(s) per Year Benefit Explanation: Two cleanings, two X-rays (one full mouth, one bite wing), fluoride with cleanings (up to age 14, limit two per year), and sealants (up to age 14 on permanent molars only) per year.
Routine Dental Checkups for Adults	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Limit Quantity: 2 Limit Unit : Exam(s) per Year Benefit Explanation: Two cleanings and two x-rays (one full mouth, one bite wing) per year.
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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