Wisconsin health plan · 2025

CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam) · 87416WI0060012

Common Ground Healthcare Cooperative offers this marketplace health insurance plan (Plan ID 87416WI0060012) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Silver Plan type: EPO CSR: Standard Silver On Exchange Plan Issuer: Common Ground Healthcare Cooperative
Telehealth Data pending HSA eligible No Dental Not listed Vision Adult/Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 70.06%. Expect to pay roughly 29.94% of covered costs out of pocket, based on issuer reporting.

CMS AV Calculator output: 70.06% (29.94% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$285 – $1410

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$9,200

$18400 per group

Review MOOP rules

Office visits

Primary care $55.00
Specialist $110.00
HSA Not eligible

Drug tiers

Generic $10.00
Preferred brand $80.00

View formulary tiers

$429 / mo before subsidies

≈ $5153 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1271 / mo before subsidies

≈ $15251 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1552 / mo before subsidies

≈ $18622 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$966 / mo before subsidies

≈ $11591 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

$250.00

Durable Medical Equipment

30.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Wisconsin). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Silver On Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

$250.00

Durable Medical Equipment

30.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 87416WI0060012
Coverage year 2025
State Wisconsin
Issuer Common Ground Healthcare Cooperative
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 87416WI0060012-01
Available variants

Standard Off Exchange Plan · 87416WI0060012-00

Standard On Exchange Plan · 87416WI0060012-01

Open to Indians below 300% FPL · 87416WI0060012-02

Open to Indians above 300% FPL · 87416WI0060012-03

73% AV Silver Plan · 87416WI0060012-04

87% AV Silver Plan · 87416WI0060012-05

94% AV Silver Plan · 87416WI0060012-06
Last plan update Wed, 04 Dec 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in Wisconsin 114
PCPs in Wisconsin 14
Telehealth support Data pending
Nationwide providers 123
114 doctors statewide 14 PCPs

Provider network(s)

Providers Wisconsin All US states
All 114 123
PCP 14 19
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 2 2

Drug coverage overview

4,229 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
GENERIC 2,435
INSULIN-DISCOUNT 1,404
SPECIALTY 374
NON-PREFERRED-BRAND 16
Prior authorization Drugs
Required 777
Not Required 3,452
Step therapy Drugs
Required 214
Not Required 4,015
Quantity limits Drugs
Has Limit 1,383
No Limit 2,846

Customer highlights

What stands out for members

  • Issuer: Common Ground Healthcare Cooperative · Plan ID 87416WI0060012 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 87416WI0060012-01 (Standard On Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$55.00
Tier 1 in-network $55.00
Out-of-network 100.00%

Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.

Exclusions: nan

Diabetes Education

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Home Health Care Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.

Exclusions: nan

Laboratory Outpatient and Professional Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$55.00
Tier 1 in-network $55.00
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$55.00
Tier 1 in-network $55.00
Out-of-network 100.00%

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Year

Separate limits for OT and PT.

Exclusions: nan

Rehabilitative Speech Therapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term.

Exclusions: nan

Specialist Visit

$110.00
Tier 1 in-network $110.00
Out-of-network 100.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 30.00% Coinsurance after deductible

nan

Exclusions: nan

X-rays and Diagnostic Imaging

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Intravenous chemotherapy is covered.

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Dialysis

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Durable Medical Equipment

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Emergency Room Services

$250.00
Tier 1 in-network $250.00
Out-of-network $250.00

nan

Exclusions: nan

Emergency Transportation/Ambulance

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 30.00% Coinsurance after deductible

nan

Exclusions: nan

Hospice Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Physician and Surgical Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$55.00
Tier 1 in-network $55.00
Out-of-network 100.00%

The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Exclusions: nan

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Rehabilitation Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Rehabilitative services must be short term.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Radiation

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 30.0 Days per Stay

nan

Exclusions: nan

Substance Abuse Disorder Inpatient Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$55.00
Tier 1 in-network $55.00
Out-of-network 100.00%

The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Exclusions: nan

Transplant

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Item(s) per 3 Years

nan

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Routine Eye Exam for Children

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

nan

Exclusions: nan

Well Baby Visits and Care

0.00%
Tier 1 in-network 0.00%
Out-of-network 100.00%

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$10.00
Tier 1 in-network $10.00
Out-of-network 100.00%

Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process

Exclusions: nan

Non-Preferred Brand Drugs

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process. On Cost Sharing Reduction (CSR) 73% and 87% plans, coinsurance applies once the plans medical deductible is met.

Exclusions: nan

Preferred Brand Drugs

$80.00
Tier 1 in-network $80.00
Out-of-network 100.00%

Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process. $15 Copay for Preferred Insulin for Gold and Silver plans.

Exclusions: nan

Specialty Drugs

40.00% Coinsurance after deductible
Tier 1 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process. On Cost Sharing Reduction (CSR) 73% and 87% plans, coinsurance applies once the plans medical deductible is met.

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

Coverage details pending

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

Coverage details pending

nan

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Eye Glasses for Children

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 1.0 Item(s) per Year

nan

Exclusions: nan

Gender Affirming Care

Coverage details pending

nan

Exclusions: nan

Habilitation Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Infertility Treatment

Coverage details pending

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

Coverage details pending

nan

Exclusions: nan

Reconstructive Surgery

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Routine Eye Exam (Adult)

$0.00
Tier 1 in-network $0.00
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Variant attributes

CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam) · Variant 87416WI0060012-01

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard Silver On Exchange Plan

HIOS Product ID

87416WI006

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

87416WI0060012-01

Plan Marketing Name

CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam)

Plan Variant Marketing Name

CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam)

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

70.06%

Issuer ID

87416

Issuer Marketplace Marketing Name

Common Ground Healthcare Cooperative

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

WIN001

Out of Country Coverage

Yes

Out of Country Coverage Description

Emergency Services Only

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

Emergency Services Only

Service Area ID

WIS001

State Code

WI

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.700580909354928

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

30.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

30.00%

SBC Scenario, Having a Baby, Coinsurance

$2,500

SBC Scenario, Having a Baby, Copayment

$10

SBC Scenario, Having a Baby, Deductible

$4,200

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$1,000

SBC Scenario, Having Diabetes, Deductible

$900

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$600

SBC Scenario, Treatment of a Simple Fracture, Deductible

$2,100

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

Not Applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$18400 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$9200 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$9,200

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

Not Applicable

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

WIF004

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Drug EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Drug EHB Deductible, In Network (Tier 1), Family Per Group

$10000 per group

Drug EHB Deductible, In Network (Tier 1), Family Per Person

$5000 per person

Drug EHB Deductible, In Network (Tier 1), Individual

$5,000

Drug EHB Deductible, Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Out of Network, Individual

Not Applicable

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy

EHB Percent of Total Premium

0.998635152089645

First Tier Utilization

100%

Import Date

2024-12-04 00:01:33

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

Yes

Is a Referral Required for Specialist?

No

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Group

$8400 per group

Medical EHB Deductible, In Network (Tier 1), Family Per Person

$4200 per person

Medical EHB Deductible, In Network (Tier 1), Individual

$4,200

Medical EHB Deductible, Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Out of Network, Individual

Not Applicable

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

EPO

QHP/Non QHP

Both

Source Name

HIOS

Plan ID

87416WI0060012

Unique Plan Design

Yes

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Wisconsin?

CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam) (87416WI0060012) is a Silver EPO from Common Ground Healthcare Cooperative in Wisconsin for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam) support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam) HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Adult, Child.

Does CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam) support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam)?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy.

Is there out-of-country coverage for CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam)?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Emergency Services Only

Does CGHC Silver $4200 Ded / $5000 Rx Ded - Envision Network (Vision Exam) cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Emergency Services Only

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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