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| Services | CSR 100 | CSR 150 | CSR 200 | 1/250 |
|---|---|---|---|---|
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Value Basics
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Teladoc Virtual Care Visits 24/7/365
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FREE | FREE | FREE | FREE |
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Annual Wellness Visit ? Adults
|
FREE | FREE | FREE | FREE |
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Routine Preventive Screenings ? Children & Adults
|
FREE | FREE | FREE | FREE |
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Routine Vision Exams & eyewear for Children (0-18)
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FREE | FREE | FREE | FREE |
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Preventive Prescription Drugs
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FREE | FREE | FREE | FREE |
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24 Hour Nurse Line
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FREE | FREE | FREE | FREE |
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Urgent Care at Same Cost as Primary Physician Visit
|
YES | YES | YES | YES |
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Plan Options with Adult Vision Services
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YES | YES | YES | YES |
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Benefit and Cost Share Highlights
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Deductible (Ind/Fam)
|
$0/$0 | $0/$0 | $0/$0 | $0/$0 |
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Out-of-Pocket Max (Ind/Fam)
|
$1,200/$2,400 | $2,800/$5,600 | $6,700 / $13,400 | $8,500 / $17,000 |
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Drug Deductible (Ind/Fam)
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$0/$0 | $150/$300 Rx tiers 3&4 only |
$350/$700 Rx tiers 3&4 only |
$800 / $1,600 Rx Tiers 3&4 Only |
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Emergency Room Services
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$250 | $400 | $750 | $750 |
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Hospital / Facility Services
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Inpatient Hospital
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$600/day (max 2 copays) |
$750/day (max 2 copays) |
$1,200/day (max 2 copays) |
$1,200/day (max 2 copays) |
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Skilled Nursing Facility Services
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$600/day | $750/day | $1,200/day | $1,200/day |
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Hospital Physician Services
|
$10 | $30 | $60 | $60 |
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Outpatient Surgery Services
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$100 | $350 | $500 | $500 |
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Outpatient Services
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Primary & Urgent Care Services
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$0 | $6 | $30 | $30 |
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Specialist Services
|
$10 | $30 | $60 | $60 |
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Mental/Behavioral Health Services
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$0 | $6 | $30 | $30 |
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Imaging & Specialized Radiology
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$50 | $400 | $700 | $700 |
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Rehabilitative Services -ST, OT, PT
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$10 | $30 | $60 | $60 |
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Routine Laboratory Services
|
$5 | $20 | $45 | $45 |
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Routine X-Ray & Diagnostic Services
|
$15 | $50 | $80 | $80 |
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Prescription Drugs
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Tier 1 ? Preferred Generic Drugs
|
$0 | $5 | $20 | $29 |
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Tier 2 ? Preferred Brand Drugs
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$10 | $25 | $60 | $60 |
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Tier 3 ? Non-Pref Brand & Generic Drugs
|
10% | 40% after ded | 40% after ded | 40% after ded |
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Tier 4 ? Specialty Drugs
|
10% | 40% after ded | 40% after ded | 40% after ded |
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