| Services | CSR 100 | CSR 150 | CSR 200 | 7/250 |
|---|---|---|---|---|
|
Value Basics
|
||||
|
Teladoc Virtual Care Visits 24/7/365
|
FREE | FREE | FREE | FREE |
|
Annual Wellness Visit ? Adults
|
FREE | FREE | FREE | FREE |
|
Routine Preventive Screenings ? Children & Adults
|
FREE | FREE | FREE | FREE |
|
Routine Vision Exams & eyewear for Children (0-18)
|
FREE | FREE | FREE | FREE |
|
Preventive Prescription Drugs
|
FREE | FREE | FREE | FREE |
|
24 Hour Nurse Line
|
FREE | FREE | FREE | FREE |
|
Urgent Care at Same Cost as Primary Physician Visit
|
YES | YES | YES | YES |
|
Plan Options with Adult Vision Services
|
Not Available | Not Available | Not Available | Not Available |
|
Benefit & Cost Share Highlights
|
||||
|
Deductible (Ind/Fam)
|
$0 / $0 | $0 / $0 | $0 / $0 | $0 / $0 |
|
Out-of-Pocket Max (Ind/Fam)
|
$1,200 / $2,400 | $2,850 / $5,700 | $6,800 / $13,600 | $8,550 / $17,100 |
|
Drug Deductible (Ind/Fam)
|
$0 / $0 | $80 / $160 Rx Tiers 3&4 Only |
$350 / $700 Rx Tiers 3&4 Only |
$1,350 / $2,700 Rx Tiers 3&4 Only |
|
Emergency Room Services
|
$250 | $600 | $750 | $1,250 |
|
Hospital / Facility Services
|
||||
|
Inpatient Hospital
|
$200/day (max 2 copays) |
$375/day (max 2 copays) |
$600/day (max 2 copays) |
$600/day (max 2 copays) |
|
Skilled Nursing Facility Services
|
$200/day | $375/day | $600/day | $600/day |
|
Hospital Physician Services
|
$10 | $30 | $75 | $90 |
|
Outpatient Surgery Services
|
$120 | $120 | $150 | $150 |
|
Outpatient Services
|
||||
|
Primary & Urgent Care Services
|
$0 | $5 | $25 | $30 |
|
Specialist Services
|
$10 | $30 | $75 | $90 |
|
Mental/Behavioral Health Services
|
$0 | $5 | $25 | $30 |
|
Imaging & Specialized Radiology
|
$100 | $400 | $700 | $700 |
|
Rehabilitative Services -ST, OT, PT
|
$10 | $40 | $60 | $60 |
|
Routine Laboratory Services
|
$20 | $30 | $50 | $50 |
|
Routine X-Ray & Diagnostic Services
|
$30 | $60 | $100 | $135 |
|
Prescription Drugs
|
||||
|
Tier 1 ? Preferred Generic Drugs
|
$0 | $8 | $25 | $30 |
|
Tier 2 ? Preferred Brand Drugs
|
$10 | $35 | $75 | $100 |
|
Tier 3 ? Non-Pref Brand & Generic Drugs
|
10% | 10% after Rx ded | 40% after Rx ded | 40% after Rx ded |
|
Tier 4 ? Specialty Drugs
|
10% | 10% after Rx ded | 40% after Rx ded | 40% after Rx ded |
0 Comments