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INDIVIDUALS AND FAMILIES

Compare all plan options below

Individual and Family Plans

Catastrophic Bronze 6850/100 Bronze HSA Silver HSA Silver 2400/80 Silver 1800/80 Silver
3600/80
Silver 2400/80/
Copay 35
Gold 1000/90 Gold 600/80
Deductible – In-Network $6,850/
$13,700
$6,850/
$13,700
$5,650/
11,300
$3,000/
$6,000
$2,400/
$4,800
$1,800/
$3,600
$3,600/
$7,200
$2,400/
$4,800
$1,000/
$2,000
$600/
$1,200
Your deductible increases when you go out of network.
(Single/Family)
$13,700/
$27,400
$13,700/
$27,400
$11,300/
$22,600
$6,000/
$12,000
$4,800/
$9,600
$3,600/
$7,200
$7,200/
$14,400
$4,800/
$9,600
$2,000/
$4,000
$1,200/
$2,400
Out-of-Pocket Maximum
In-Network
(Single/Family)
$6,850/
$13,700
$6,850/
$13,700
$6,500/
$13,000
$4,500/
$9,000
$6,850/
$13,700
$6,850/
$13,700
$6,850/
$13,700
$6,850/
$13,700
$6,850/
$13,700
$6,850/
$13,700
Out-of-Pocket Maximum
Out-of-Network
(Single/Family)
$27,400/
$54,800
$27,400/
$54,800
$13,000/
$26,000
$9,000/
$18,000
$13,700/
$27,400
$13,700/
$27,400
$13,700/
$27,400
$13,700/
$27,400
$13,700/
$27,400
$13,700/
$27,400
Coinsurance In-Network
(you pay)
0% 0% 10% 20% 20% 20% 20% 20% 10% 20%
Coinsurance Out-of-Network
(you pay)
30% 30% 40% 50% 50% 50% 50% 50% 40% 50%
PCP1 (In-Network) $0 for 3;
Deductible
$35 for 3;
Deductible
Ded/
Coins
Ded/
Coins
Ded/
Coins
Ded/
Coins
$35 Copay $35 Copay $35 Copay $35 Copay
Specialist (In-Network) Deductible Deductible Ded/
Coins
Ded/
Coins
Ded/
Coins
Ded/
Coins
$60 Copay $60 Copay $60 Copay $60 Copay
Urgent Care (In-Network) Deductible Deductible Ded/
Coins
Ded/
Coins
Ded/
Coins
Ded/
Coins
$35 Copay $35 Copay $35 Copay $35 Copay
CGHC Doctor Line2 $0 for 3 $0 for 3 $0 for 3 $0 for 3 $0 for 3 $0 for 3 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Emergency Room4 (In- & Out-of-Network) In-Network
Deductible
In-Network Deductible In-Network Ded/Coins In-Network Ded/Coins In-Network Ded/Coins In-Network Ded/Coins $250 Copay $250 Copay $250 Copay $250 Copay
Prescription Drugs (Tier 1) Deductible Deductible Ded/Coins Ded/Coins Ded/Coins Ded/Coins $25 Copay $25 Copay $10 Copay $10 Copay
Prescription Drugs (Tier 2) Deductible Deductible Ded/Coins Ded/Coins Ded/Coins Ded/Coins $50 Copay $50 Copay $45 Copay $45 Copay
Prescription Drugs (Tier 3) Deductible Deductible Ded/Coins Ded/Coins Ded/Coins Ded/Coins $75 Copay $75 Copay $75 Copay $75 Copay
Prescription Drugs (Specialty) Deductible Deductible Ded/Coins Ded/Coins Ded/Coins Ded/Coins Ded/Coins Ded/Coins Ded/Coins Ded/Coins
More Details More Details More Details More Details More Details More Details More Details More Details More Details More Details
Catastrophic Bronze 6850/100 Bronze HSA
Deductible – In-Network
(Single/Family)
$6,850/$13,700 $6,850/$13,700 $5,650\$11,300
Your deductible increases when you go out of network.
(Single/Family)
$13,700/$27,400 $13,700/$27,400 $11,300/$22,600
Out-of-Pocket Maximum – In-Network (Single/Family) $6,850/$13,700 $6,850/$13,700 $6,500/$13,000
Out-of-Pocket Maximum – Out-of-Network (Single/Family) $27,400/$54,800 $27,400/$54,800 $13,000/$26,000
Coinsurance In-Network
(you pay)
0% 0% 10%
Coinsurance Out-of-Network (you pay) 30% 40% 30%
PCP1 (In-Network) $0 for 3; Deductible $35 for 3; Deductible Ded/Coins
Specialist (In-Network) Deductible Deductible Ded/Coins
Urgent Care (In-Network) Deductible Deductible Ded/Coins
CGHC Doctor Line2 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0
Emergency Room4 (In- & Out-of-Network) In-Network Deductible In-Network Deductible In-Network Deductible
Prescription Drugs (Tier 1) Deductible Deductible Ded/Coins
Prescription Drugs (Tier 2) Deductible Deductible Ded/Coins
Prescription Drugs (Tier 3) Deductible Deductible Ded/Coins
Prescription Drugs (Specialty) Deductible Deductible Ded/Coins
More Details More Details More Details
Silver HSA Silver 2400/80 Silver 1800/80 Silver 3600/80 Silver 2400/80/
Copay 35
Deductible – In-Network
(Single/Family)
$3,000/$6,000 $2,400/$4,800 $1,800/$3,600 $3,600/$7,200 $2,400/$4,800
Your deductible increases when you go out of network.
(Single/Family)
$6,000/$12,000 $4,800/$9,600 $3,600/$7,200 $7,200/$14,400 $4,800/$9,600
Out-of-Pocket Maximum – In-Network
(Single/Family)
$4,500/$9,000 $6,850/$13,700 $6,850/$13,700 $6,850/$13,700 $6,850/$13,700
Out-of-Pocket Maximum – Out-of-Network
(Single/Family)
$9,000/$18,000 $13,700/$27,400 $13,700/$27,400 $13,700/$27,400 $13,700/$27,400
Coinsurance In-Network
(you pay)
20% 20% 20% 20% 20%
Coinsurance Out-of-Network (you pay) 50% 50% 50% 50% 50%
PCP1 (In-Network) Ded/Coins Ded/Coins Ded/Coins $35 Copay $35 Copay
Specialist (In-Network) Ded/Coins Ded/Coins Ded/Coins $60 Copay $60 Copay
Urgent Care (In-Network) Ded/Coins Ded/Coins Ded/Coins $35 Copay $35 Copay
CGHC Doctor Line2 $0 for 3 $0 for 3 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0 $0 $0
Emergency Room4 (In- & Out-of-Network) In-Network Ded/Coins In-Network Ded/Coins In-Network Ded/Coins $250 Copay $250 Copay
Prescription Drugs (Tier 1) Ded/Coins Ded/Coins Ded/Coins $25 Copay $25 Copay
Prescription Drugs (Tier 2) Ded/Coins Ded/Coins Ded/Coins $50 Copay $50 Copay
Prescription Drugs (Tier 3) Ded/Coins Ded/Coins Ded/Coins $75 Copay $75 Copay
Prescription Drugs (Specialty) Ded/Coins Ded/Coins Ded/Coins Ded/Coins Ded/Coins
More Details More Details More Details More Details More Details
Gold 1000/90 Gold 600/80
Deductible – In-Network
(Single/Family)
$1,000/$2,000 $600/$1,200
Your deductible increases when you go out of network.
(Single/Family)
$2,000/$4,000 $1,200/$2,400
Out-of-Pocket Maximum – In-Network
(Single/Family)
$6,850/$13,700 $6,850/$13,700
Out-of-Pocket Maximum – Out-of-Network
(Single/Family)
$13,700/$27,400 $13,700/$27,400
Coinsurance In-Network
(you pay)
10% 20%
Coinsurance Out-of-Network (you pay) 40% 50%
PCP1 (In-Network) $35 Copay $35 Copay
Specialist (In-Network) $60 Copay $60 Copay
Urgent Care (In-Network) $35 Copay $35 Copay
CGHC Doctor Line2 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0
Emergency Room4 (In- & Out-of-Network) $250 Copay $250 Copay
Prescription Drugs (Tier 1) $10 Copay $10 Copay
Prescription Drugs (Tier 2) $45 Copay $45 Copay
Prescription Drugs (Tier 3) $75 Copay $75 Copay
Prescription Drugs (Specialty) Ded/Coins Ded/Coins
More Details More Details

Click the links below to access the Schedule of Benefits for these 2015 plans:

Catastrophic   |   Bronze 5800/100   |   Bronze HSA

Silver 1500/80   |   Silver 2000/80   |   Silver HSA 2500/80

Silver 2000/80/Copay 30   |   Silver 3000/80/Copay 30

Gold 500/90   |   Gold 500/80

All plans offer the American Indian/Alaskan Native Plan Variations (Limited Cost Sharing and No Cost Sharing) for eligible individuals.  Please click here for more information about those plan variations.

1 PCP = Primary Care Provider (includes general pediatrics, internal medicine, OB/GYN, family practice, general medicine, chiropractor and geriatrics) Urgent = Urgent Care Services Emergency = Emergency Room Care Services

2 CGHC Doctor Line – This service makes available to our members phone calls with a licensed physician. 3 no-cost doctor line calls are provided per non-HSA policy holder. Total visits are capped at 3 within 3 months or 8 within 12 months.

3 Preventive care received out of network is not covered.

4 Services that meet the definition of emergency are covered as in network even when care is delivered in a non-network ER. The copay will apply only to the facility charge. All other charges related to ER visit are subject to deductible/coinsurance.

Our Deductibles, Explained: All plans have a January 1 to December 31 deductible. All deductibles, coinsurance, and copayments accumulate toward the out-of-pocket maximum. In-network and out-of-network deductibles and out-of-pocket maximums must be satisfied separately. All plans described on this page have embedded deductibles for family coverage. This means that if you are enrolled in 2-person or family coverage, an individual family member only has to satisfy the single person deductible before the plan begins to make payment for covered services for that family member. 

Cost Share Reduction Plans (Silver Base Plans)

73% – 2400/Copay 30 CSR 87% – $0 Ded/Copay 25 CSR 94% – $0 Ded/Copay 5/Max 600 CSR
Deductible – In-Network
(Single/Family)
$2,400/$4,800 $0/$0 $0/$0
Your deductible increases when you go out of network.
(Single/Family)
$4,800/$9,600 $2,500/$5,000 $2,500/$5,000
Out-of-Pocket Maximum
In-Network (Single/Family)
$5,450/$10,900 $2,250/$4,500 $600/$1,200
Out-of-Pocket Maximum
Out-of-Network (Single/Family)
$10,900/$21,800 $5,000/$10,000 $5,000/$10,000
Coinsurance In-Network
(you pay)
20% 20% 20%
Coinsurance Out-of-Network
(you pay)
50% 50% 50%
PCP1 (In-Network) $30 Copay $25 Copay $5 Copay
Specialist (In-Network) $50 Copay $40 Copay $10 Copay
Urgent Care (In-Network) $30 Copay $25 Copay $5 Copay
CGHC Doctor Line2 $0 for 3 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0
Emergency Room4(In- & Out-of-Network) $250 Copay $200 Copay $100 Copay
Prescription Drugs (Tier 1) $20 Copay $10 Copay $5 Copay
Prescription Drugs (Tier 2) $50 Copay $50 Copay $15 Copay
Prescription Drugs (Tier 3) $75 Copay $75 Copay $35 Copay
Prescription Drugs (Specialty) Ded/Coins Ded/Coins Ded/Coins
More Details More Details More Details
73% – 2400/Copay 35 CSR 87% – $0 Ded/Copay 30 CSR 94% – $0 Ded/Copay 5/Max 1,000 CSR
Deductible – In-Network
(Single/Family)
$2,400/$4,800 $0/$0 $0/$0
Your deductible increases when you go out of network.
(Single/Family)
$4,800/$9,600 $2,500/$5,000 $2,500/$5,000
Out-of-Pocket Maximum
In-Network (Single/Family)
$5,450/$10,900 $2,250/$4,500 $1,000/$2,000
Out-of-Pocket Maximum
Out-of-Network (Single/Family)
$10,900/$21,800 $5,000/$10,000 $5,000/$10,000
Coinsurance In-Network
(you pay)
20% 20% 20%
Coinsurance Out-of-Network (you pay) 50% 50% 50%
PCP1 (In-Network) $35 Copay $30 Copay $5 Copay
Specialist (In-Network) $50 Copay $40 Copay $10 Copay
Urgent Care (In-Network) $35 Copay $30 Copay $5 Copay
CGHC Doctor Line2 $0 for 3 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0
Emergency Room4 (In- & Out-of-Network) $250 Copay $200 Copay $100 Copay
Prescription Drugs (Tier 1) $20 Copay $10 Copay $10 Copay
Prescription Drugs (Tier 2) $50 Copay $50 Copay $15 Copay
Prescription Drugs (Tier 3) $75 Copay $75 Copay $40 Copay
Prescription Drugs (Specialty) Ded/Coins Ded/Coins Ded/Coins
More Details More Details More Details
73% – 1500/80 CSR 87% – 150/80 CSR 94% – $0 Ded/Max 550 CSR
Deductible – In-Network
(Single/Family)
$1,500/$3,000 $150/$300 $0/$0
Your deductible increases when you go out of network.
(Single/Family)
$3,000/$6,000 $2,500/$5,000 $2,500/$5,000
Out-of-Pocket Maximum
In-Network (Single/Family)
$5,450/$10,900 $2,250/$4,500 $550/$1,100
Out-of-Pocket Maximum
Out-of-Network (Single/Family)
$10,900/$21,800 $5,000/$10,000 $5,000/$10,000
Coinsurance In-Network
(you pay)
20% 20% 20%
Coinsurance Out-of-Network (you pay) 50% 50% 50%
PCP1 (In-Network) Ded/Coins Ded/Coins Ded/Coins
Specialist (In-Network) Ded/Coins Ded/Coins Ded/Coins
Urgent Care (In-Network) Ded/Coins Ded/Coins Ded/Coins
CGHC Doctor Line2 $0 for 3 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0
Emergency Room4 (In- & Out-of-Network) In-Network Ded/Coins In-Network Ded/Coins In-Network Ded/Coins
Prescription Drugs (Tier 1) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Tier 2) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Tier 3) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Specialty) Ded/Coins Ded/Coins Ded/Coins
More Details More Details More Details
73% – 1600/80 CSR 87% – 200/80 CSR 94% – $0 Ded/Max 830 CSR
Deductible – In-Network
(Single/Family)
$1,600/$3,200 $200/$400 $0/$0
Your deductible increases when you go out of network.
(Single/Family)
$3,200/$6,400 $2,500/$5,000 $2,500/$5,000
Out-of-Pocket Maximum
In-Network (Single/Family)
$5,450/$10,900 $2,250/$4,500 $830/$1,660
Out-of-Pocket Maximum
Out-of-Network (Single/Family)
$10,900/$21,800 $5,000/$10,000 $5,000/$10,000
Coinsurance In-Network
(you pay)
20% 20% 20%
Coinsurance Out-of-Network (you pay) 50% 50% 50%
PCP1 (In-Network) Ded/Coins Ded/Coins Ded/Coins
Specialist (In-Network) Ded/Coins Ded/Coins Ded/Coins
Urgent Care (In-Network) Ded/Coins Ded/Coins Ded/Coins
CGHC Doctor Line2 $0 for 3 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0
Emergency Room4 (In- & Out-of-Network) In-Network Ded/Coins In-Network Ded/Coins In-Network Ded/Coins
Prescription Drugs (Tier 1) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Tier 2) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Tier 3) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Specialty) Ded/Coins Ded/Coins Ded/Coins
More Details More Details More Details
73% – 1900/80 CSR5 87% – 250/80 CSR5 94% – $50 Ded/Max 760 CSR5
Deductible – In-Network
(Single/Family)
$1,900/$3,800 $250/$500 $50/$100
Your deductible increases when you go out of network.
(Single/Family)
$3,800/$7,600 $2,500/$5,000 $2,500/$5,000
Out-of-Pocket Maximum
In-Network (Single/Family)
$4,500/$9,000 $2,250/$4,500 $760/$1,520
Out-of-Pocket Maximum
Out-of-Network (Single/Family)
$9,000/$18,000 $5,000/$10,000 $5,000/$10,000
Coinsurance In-Network
(you pay)
20% 20% 20%
Coinsurance Out-of-Network (you pay) 50% 50% 50%
PCP1 (In-Network) Ded/Coins Ded/Coins Ded/Coins
Specialist (In-Network) Ded/Coins Ded/Coins Ded/Coins
Urgent Care (In-Network) Ded/Coins Ded/Coins Ded/Coins
CGHC Doctor Line2 $0 for 3 $0 for 3 $0 for 3
In-Network Preventive Care3 $0 $0 $0
Emergency Room4 (In- & Out-of-Network) In-Network Ded/Coins In-Network Ded/Coins In-Network Ded/Coins
Prescription Drugs (Tier 1) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Tier 2) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Tier 3) Ded/Coins Ded/Coins Ded/Coins
Prescription Drugs (Specialty) Ded/Coins Ded/Coins Ded/Coins
More Details More Details More Details

Click the links below to access the Schedule of Benefits for these 2015 plans:

 Silver 3000/80/Copay 30

Alternate 2000/80 Copay 30A  |  Alternate Copay 5A  |  Alternate Copay 30A

Silver 2000/80/Copay 30

Alternate 2000/80 Copay 30B  |  Alternate Copay 5B  |  Alternate Copay 30B

Silver HSA 2500/80

Alternate HSA 50/80  |  Alternate HSA 250/80  |  Alternate HSA 1700/80

Silver 2000/80

Alternate 0/80A  |  Alternate 100/80A  |  Alternate 1300/80A

Silver 1500/80

Alternate 0/80B  |  Alternate 100/80B  |  Alternate 1300/80B

1 PCP = Primary Care Provider (includes general pediatrics, internal medicine, OB/GYN, family practice, general medicine, chiropractor and geriatrics) Urgent = Urgent Care Services Emergency = Emergency Room Care Services

2 CGHC Doctor Line – This service makes available to our members phone calls with a licensed physician. 3 no-cost doctor line calls are provided per non-HSA policy holder. Total visits are capped at 3 within 3 months or 8 within 12 months.

3 Preventive care received out of network is not covered.

4 Services that meet the definition of emergency are covered as in network even when care is delivered in a non-network ER. The copay will apply only to the facility charge. All other charges related to ER visit are subject to deductible/coinsurance.

5 HSA Plan CSRs – None of the CSR variations for the Envision Silver HSA 3000/80 are HSA compatible.

Our Deductibles, Explained: All plans have a January 1 to December 31 deductible. All deductibles, coinsurance, and copayments accumulate toward the out-of-pocket maximum. In-network and out-of-network deductibles and out-of-pocket maximums must be satisfied separately. All plans described on this page have embedded deductibles for family coverage. This means that if you are enrolled in 2-person or family coverage, an individual family member only has to satisfy the single person deductible before the plan begins to make payment for covered services for that family member.

Common Ground Healthcare Cooperative does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

This page provides summary information.  Please refer to the certificate of coverage and schedule of benefits for a complete listing of benefits and terms of coverage.  A list of exclusions and limitations can be found here.