2024 Summary of Benefits & Coverage
(SBC)
2024 On-Exchange Base Plan SBCs
Click the links below to access the Summary of Benefits & Coverage (SBC) for these plans:
Gold Plans
- CGHC Copay Gold $0 Ded – Envision Network
- CGHC Gold $3000 – Envision Network
- CGHC Gold $1800 – Envision Network
- CGHC HSA Gold $3200 – Envision Network
- CGHC Gold Standard $1500 – Envision Network
- CGHC Gold $1800 – Envision Network (Vision Exam)
- CGHC Gold $3000 – Envision Network (Vision Exam)
- CGHC HSA Gold $3200 – Envision Network (Vision Exam)
- CGHC Copay Gold $0 Ded – Envision Network (Vision Exam)
Silver Plans
- CGHC Silver $4000 – Envision Network
- CGHC Silver $5000 Ded / $5000 Rx Ded – Envision Network
- CGHC HSA Silver $3200 – Envision Network
- CGHC Silver Standard $5900 – Envision Network
- CGHC Silver $5650 Ded / $6000 Rx Ded – Envision Network
- CGHC Silver $4000 – Envision Network (Vision Exam)
- CGHC Silver $5650 Ded / $6000 Rx Ded – Envision Network (Vision Exam)
- CGHC Silver $5000 Ded / $5000 Rx Ded – Envision Network (Vision Exam)
- CGHC HSA Silver $3200 – Envision Network (Vision Exam)
- CGHC Silver $5650 Ded / $6000 Rx Ded – Envision Network (Dental/Vision Exam)
- CGHC Silver $5000 Ded / $5000 Rx Ded – Envision Network (Dental/Vision Exam)
Bronze/Catastrophic Plans
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded – Envision Network
- CGHC Catastrophic $9450 – Envision Network
- CGHC Bronze $9450 ($35 PCP Copay) – Envision Network
- CGHC HSA Bronze $7500 – Envision Network
- CGHC Bronze $6000 – Envision Network
- CGHC Bronze Standard $7500 – Envision Network
- CGHC Bronze $9450 ($35 PCP Copay) – Envision Network (Vision Exam)
- CGHC Bronze $6000 – Envision Network (Vision Exam)
- CGHC HSA Bronze $7500 – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded – Envision Network (Dental/Vision Exam)
All On-Exchange plans offer variants with Adult Vision and some with Preventive Dental add-on options. Click here to learn more.
Prescription Drug List | Certificate of Coverage
2024 On-Exchange Cost-Sharing Reduction Plan SBCs
Click the links below to access the Summary of Benefits and Coverage (SBC) for these plans:
73% CSR Plans
- CGHC Silver $3600 CSR 73% – Envision Network
- CGHC Silver $4000 CSR 73% – Envision Network
- CGHC Silver $2850 CSR 73% – Envision Network
- CGHC Silver Standard $5700 CSR 73% – Envision Network
- CGHC Silver $4050 CSR 73% – Envision Network
- CGHC Silver $3600 CSR 73% – Envision Network (Vision Exam)
- CGHC Silver $4050 CSR 73% – Envision Network (Vision Exam)
- CGHC Silver $4000 CSR 73% – Envision Network (Vision Exam)
- CGHC Silver $2850 CSR 73% – Envision Network (Vision Exam)
- CGHC Silver $4050 CSR 73% – Envision Network (Dental/Vision Exam)
- CGHC Silver $4000 CSR 73% – Envision Network (Dental/Vision Exam)
87% CSR Plans
- CGHC Silver $700 CSR 87% – Envision Network
- CGHC Silver $600 CSR 87% – Envision Network
- CGHC Silver $850 CSR 87% – Envision Network
- CGHC Silver Standard $700 CSR 87% – Envision Network
- CGHC Silver $600 CSR 87% ($25 PCP Copay) – Envision Network
- CGHC Silver $700 CSR 87% – Envision Network (Vision Exam)
- CGHC Silver $600 CSR 87% ($25 PCP Copay) – Envision Network (Vision Exam)
- CGHC Silver $600 CSR 87% – Envision Network (Vision Exam)
- CGHC Silver $850 CSR 87% – Envision Network (Vision Exam)
- CGHC Silver $600 CSR 87% ($25 PCP Copay) – Envision Network (Dental/Vision Exam)
- CGHC Silver $600 CSR 87% – Envision Network (Dental/Vision Exam)
94% CSR Plans
- CGHC Silver $150 CSR 94% – Envision Network
- CGHC Silver $0 CSR 94% – Envision Network
- CGHC Silver $250 CSR 94% – Envision Network
- CGHC Silver Standard $0 CSR 94% – Envision Network
- CGHC Silver $0 CSR 94% ($0 PCP Copay) – Envision Network
- CGHC Silver $150 CSR 94% – Envision Network (Vision Exam)
- CGHC Silver $0 CSR 94% ($0 PCP Copay) – Envision Network (Vision Exam)
- CGHC Silver $0 CSR 94% – Envision Network (Vision Exam)
- CGHC Silver $250 CSR 94% – Envision Network (Vision Exam)
- CGHC Silver $0 CSR 94% ($0 PCP Copay) – Envision Network (Dental/Vision Exam)
- CGHC Silver $0 CSR 94% – Envision Network (Dental/Vision Exam)
Some On-Exchange plans offer variants with Adult Vision and some with Preventive Dental add-on options. Click here to learn more.
Prescription Drug List | Certificate of Coverage
2024 Off-Exchange Base Plan SBCs
Click the links below to access the Summary of Benefits and Coverage (SBC) for these plans:
Gold Plans
- CGHC Gold $1800 – Envision Network (Vision Exam + Allergy Test)
- CGHC Gold $3000 – Envision Network (Vision Exam + Allergy Test)
- CGHC HSA Gold $3200 – Envision Network (Vision Exam + Allergy Test)
- CGHC Copay Gold $0 Ded – Envision Network (Vision Exam + Allergy Test)
Silver Plans
- CGHC Silver $4000 – Envision Network (Vision Exam + Allergy Test)
- CGHC Silver $5650 Ded / $6000 Rx Ded – Envision Network (Vision Exam + Allergy Test)
- CGHC Silver $5000 Ded / $5000 Rx Ded – Envision Network (Vision Exam + Allergy Test)
- CGHC HSA Silver $3200 – Envision Network (Vision Exam + Allergy Test)
- CGHC Silver $5650 Ded / $6000 Rx Ded – Envision Network (Dental/Vision Exam + Allergy Test)
- CGHC Silver $5000 Ded / $5000 Rx Ded – Envision Network (Dental/Vision Exam + Allergy Test)
Bronze/Catastrophic Plans
- CGHC Bronze $9450 ($35 PCP Copay) – Envision Network (Vision Exam + Allergy Test)
- CGHC HSA Bronze $7500 – Envision Network (Vision Exam + Allergy Test)
- CGHC Catastrophic $9450 – Envision Network (Vision Exam + Allergy Test)
- CGHC Bronze $6000 – Envision Network (Vision Exam + Allergy Test)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded – Envision Network (Vision Exam + Allergy Test)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded – Envision Network (Dental/Vision Exam + Allergy Test)
All Off-Exchange plans offer variants with a Vision Exam and Allergy Testing and some with Preventive Dental as an add-on option. Click here to learn more.
Prescription Drug List | Certificate of Coverage
SBCs for Small Group Health Plans
2024 Small Group EPO Plans (In Service Area)
Click the links below to access the Summary of Benefits and Coverage (SBC) for these plans:
Platinum Plans
- CGHC EPO Platinum $500 Deductible/20% – Envision Network
- CGHC EPO Platinum $500 Deductible/10% – Envision Network
- CGHC EPO Platinum $500 Deductible/20% – Rise Network
- CGHC EPO Platinum $500 Deductible/10% – Rise Network
Gold Plans
- CGHC EPO Gold $0 Deductible/20% – Envision Network
- CGHC EPO Gold $800 Deductible/20% – Envision Network
- CGHC EPO Gold $1500 Deductible/20% – Envision Network
- CGHC EPO Gold $2000 Deductible/20% – Envision Network
- CGHC EPO Gold $2200 Deductible/20% – Envision Network
- CGHC EPO Gold $2600 Deductible/15% – Envision Network
- CGHC EPO Gold $2750 Deductible/15% – ER Copay – Envision Network
- CGHC EPO HSA Gold $3200 Deductible/0% – Envision Network
- CGHC EPO Gold $0 Deductible/20% – Rise Network
- CGHC EPO Gold $800 Deductible/20% – Rise Network
- CGHC EPO Gold $1500 Deductible/20% – Rise Network
- CGHC EPO Gold $2000 Deductible/20% – Rise Network
- CGHC EPO Gold $2200 Deductible/20% – Rise Network
- CGHC EPO Gold $2600 Deductible/15% – Rise Network
- CGHC EPO Gold $2750 Deductible/15% – ER Copay – Rise Network
- CGHC EPO HSA Gold $3200 Deductible/0% – Rise Network
Silver Plans
- CGHC EPO Silver $4000 Deductible/20% – Envision Network
- CGHC EPO Silver $5000 Deductible/20% – Envision Network
- CGHC EPO Silver $5500 Deductible/20% – Envision Network
- CGHC EPO Silver $6000 Deductible/20% – Envision Network
- CGHC EPO HSA Silver $3200 Deductible/20% – Envision Network
- CGHC EPO HSA Silver $5100 Deductible/0% – Envision Network
- CGHC EPO Silver $4000 Deductible/20% – Rise Network
- CGHC EPO Silver $5000 Deductible/20% – Rise Network
- CGHC EPO Silver $5500 Deductible/20% – Rise Network
- CGHC EPO Silver $6000 Deductible/20% – Rise Network
- CGHC EPO HSA Silver $3200 Deductible/20% – Rise Network
- CGHC EPO HSA Silver $5100 Deductible/0% – Rise Network
Bronze Plans
- CGHC EPO Bronze $5500 Deductible/30% – Envision Network
- CGHC EPO Bronze $8550 Deductible/0% – Envision Network
- CGHC EPO HSA Bronze $7100 Deductible/0% – Envision Network
- CGHC EPO Bronze $5500 Deductible/30% – Rise Network
- CGHC EPO Bronze $8550 Deductible/0% – Rise Network
- CGHC EPO HSA Bronze $7100 Deductible/0% – Rise Network
2024 Small Group EPO Plus Plans (Out of Service Area)
Click the links below to access the Summary of Benefits and Coverage (SBC) for these plans:
Gold Plans
- CGHC EPO Plus Gold $800 Deductible/20%
- CGHC EPO Plus Gold $1500 Deductible/20%
- CGHC EPO Plus Gold $2000 Deductible/20%
- CGHC EPO Plus HSA Gold $3200 Deductible/0%
Silver Plans
- CGHC EPO Plus Silver $4000 Deductible/20%
- CGHC EPO Plus Silver $5000 Deductible/20%
- CGHC EPO Plus HSA Silver $5100 Deductible/0%
Bronze Plans
Limited Cost Sharing (LCS) & No Cost Sharing (NCS) Plans
American Indian/Alaskan Native Plan Variations
Click the links below to access the Summary of Benefits and Coverage (SBC) for these plans:
Gold Plans
- CGHC Copay Gold $0 Ded NCS – Envision Network
- CGHC Copay Gold $0 Ded LCS – Envision Network
- CGHC Gold $3000 NCS – Envision Network
- CGHC Gold $3000 LCS – Envision Network
- CGHC Gold $1800 NCS – Envision Network
- CGHC Gold $1800 LCS – Envision Network
- CGHC Gold $3200 NCS – Envision Network
- CGHC Gold $3200 LCS – Envision Network
- CGHC Gold Standard $1500 NCS – Envision Network
- CGHC Gold Standard $1500 LCS – Envision Network
- CGHC Gold $1800 NCS – Envision Network (Vision Exam)
- CGHC Gold $1800 LCS – Envision Network (Vision Exam)
- CGHC Gold $3000 NCS – Envision Network (Vision Exam)
- CGHC Gold $3000 LCS – Envision Network (Vision Exam)
- CGHC Gold $3200 NCS – Envision Network (Vision Exam)
- CGHC Gold $3200 LCS – Envision Network (Vision Exam)
- CGHC Copay Gold $0 Ded NCS – Envision Network (Vision Exam)
- CGHC Copay Gold $0 Ded LCS – Envision Network (Vision Exam)
Silver Plans
- CGHC Silver $4000 NCS – Envision Network
- CGHC Silver $4000 LCS – Envision Network
- CGHC Silver $5000 NCS – Envision Network
- CGHC Silver $5000 Ded / $5000 Rx Ded LCS – Envision Network
- CGHC Silver $3200 NCS – Envision Network
- CGHC Silver $3200 LCS – Envision Network
- CGHC Silver Standard $5900 NCS – Envision Network
- CGHC Silver Standard $5900 LCS – Envision Network
- CGHC Silver $5650 NCS – Envision Network
- CGHC Silver $5650 Ded / $6000 Rx Ded LCS – Envision Network
- CGHC Silver $4000 NCS – Envision Network (Vision Exam)
- CGHC Silver $4000 LCS – Envision Network (Vision Exam)
- CGHC Silver $5650 NCS – Envision Network (Vision Exam)
- CGHC Silver $5650 Ded / $6000 Rx Ded LCS – Envision Network (Vision Exam)
- CGHC Silver $5000 NCS – Envision Network (Vision Exam)
- CGHC Silver $5000 Ded / $5000 Rx Ded LCS – Envision Network (Vision Exam)
- CGHC Silver $3200 NCS – Envision Network (Vision Exam)
- CGHC Silver $3200 LCS – Envision Network (Vision Exam)
- CGHC Silver $5650 NCS – Envision Network (Dental/Vision Exam)
- CGHC Silver $5650 Ded / $6000 Rx Ded LCS – Envision Network (Dental/Vision Exam)
- CGHC Silver $5000 NCS – Envision Network (Dental/Vision Exam)
- CGHC Silver $5000 Ded / $5000 Rx Ded LCS – Envision Network (Dental/Vision Exam)
Bronze Plans
- CGHC Copay Bronze $0 Ded NCS – Envision Network
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS – Envision Network
- CGHC Bronze $9450 NCS – Envision Network
- CGHC Bronze $9450 LCS ($35 PCP Copay) – Envision Network
- CGHC Bronze $7500 NCS – Envision Network
- CGHC Bronze $7500 LCS – Envision Network
- CGHC Bronze $6000 NCS – Envision Network
- CGHC Bronze $6000 LCS – Envision Network
- CGHC Bronze Standard $7500 NCS – Envision Network
- CGHC Bronze Standard $7500 LCS – Envision Network
- CGHC Bronze $9450 NCS – Envision Network (Vision Exam)
- CGHC Bronze $9450 LCS ($35 PCP Copay) – Envision Network (Vision Exam)
- CGHC Bronze $6000 NCS – Envision Network (Vision Exam)
- CGHC Bronze $6000 LCS – Envision Network (Vision Exam)
- CGHC Bronze $7500 NCS – Envision Network (Vision Exam)
- CGHC Bronze $7500 LCS – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded NCS – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded NCS – Envision Network (Dental/Vision Exam)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS – Envision Network (Dental/Vision Exam)
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 Services that meet the definition of emergency are paid at the in-network rate even when care is delivered in a non-network ER. Because we do not have a contract with out of network ER facilities, we cannot prevent these facilities from billing our members for the balance of the charge. The copay applies to the facility charge only. All other charges related to ER visit are subject to deductible/coinsurance.
3 Preventive Care received out of network is not covered
4 Catastrophic plan applies to persons under age 30 or those with a hardship exemption from the federal Marketplace (healthcare.gov)
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. 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.
To access your plan’s Summary of Benefits and Coverage (SBC), click here.
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.