Envision - Bronze 8150/100 Plan Details for 2020- HealthPocket

Envision - Bronze 8150/100

$343.68/mo

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Zip Code53215
Applicant4/6/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameEnvision - Bronze 8150/100
Plan IDhhs-87416WI0030027
Plan Year2020
Insurance ProviderCGHC
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$8,150
Out-of-Pocket Maximum$8,150
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$35 Copay
Specialist VisitNo Charge after deductible
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scansNo Charge after deductible
Deductible - Family$16300 per group
Out-of-Pocket Maximum - Family$16300 per group

Prescription drug coverage

Generic DrugsNo Charge after deductible
Preferred Brand DrugsNo Charge after deductible
Non-Preferred Brand DrugsNo Charge after deductible
Specialty DrugsNo Charge after deductible

Access to doctors and hospitals

Provider directory URLhttps://portal.commongroundhealthcare.org/Router.jsp?component=Main&source=Logon&action=ProviderDirectory
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?No - Emergency Services Only
Does this plan cover services outside the country?Yes - Emergency Services Only

Hospital services

Emergency Room ServicesNo Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance ServiceNo Charge after deductible

Maternity

Prenatal and Postnatal CareNo Charge after deductible
Delivery and all inpatient services for maternity careNo Charge after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$35 Copay
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible
Substance use disorder outpatient services$35 Copay
Substance use disorder inpatient servicesNo Charge after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Outpatient Rehabilitation Services
Durable Medical Equipment
Hospice Services
Chiropractic Care
Accidental Dental
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Habilitation Services
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Allergy Testing
Nutritional Counseling
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Daniel, Rosler
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Patricia, Cabral
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Pamela, Wilson
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Robert, Ninneman
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Kathleen, Uy
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John, Hall
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Arshad, Jahangir
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Jaime, Yamat
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Ram P. Bhala, M.d., S.c.
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Alyssa, Deppong
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Christian, Garcia
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Daniel, Jacobsen
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Diane, Aranda
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Gabrielle, Chaumet
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Kate, Cruz
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Kimberly, Paulson
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Valerie, Duncan
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Riley, Marinelli
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Jessika, Kozik
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Amanda, Kanack
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Daniel Rosler, M.D.
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  • Phone Number
    (414) 672-8550
  • Office Locations
    2901 W Kinnickinnic River Pkwy
    Milwaukee, WI 53215
2901 W Kinnickinnic River Pkwy Milwaukee WI, 53215

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HealthPocket.com provides information on insurance products. If you choose to obtain a quote or apply for an insurance plan, you may be transferred to a partner website to complete your request. Always review the privacy and terms of use of the partner website.

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).