| Services | CSR 100 | CSR 150 | CSR 200 | 1/250 |
|---|---|---|---|---|
|
Value Basics
|
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|
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
|
YES | YES | YES | YES |
|
Benefit and Cost Share Highlights
|
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|
Deductible (Ind/Fam)
|
$0/$0 | $0/$0 | $0/$0 | $0/$0 |
|
Out-of-Pocket Max (Ind/Fam)
|
$1,200/$2,400 | $2,800/$5,600 | $6,700 / $13,400 | $8,500 / $17,000 |
|
Drug Deductible (Ind/Fam)
|
$0/$0 | $150/$300 Rx tiers 3&4 only |
$350/$700 Rx tiers 3&4 only |
$800 / $1,600 Rx Tiers 3&4 Only |
|
Emergency Room Services
|
$250 | $400 | $750 | $750 |
|
Hospital / Facility Services
|
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|
Inpatient Hospital
|
$600/day (max 2 copays) |
$750/day (max 2 copays) |
$1,200/day (max 2 copays) |
$1,200/day (max 2 copays) |
|
Skilled Nursing Facility Services
|
$600/day | $750/day | $1,200/day | $1,200/day |
|
Hospital Physician Services
|
$10 | $30 | $60 | $60 |
|
Outpatient Surgery Services
|
$100 | $350 | $500 | $500 |
|
Outpatient Services
|
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|
Primary & Urgent Care Services
|
$0 | $6 | $30 | $30 |
|
Specialist Services
|
$10 | $30 | $60 | $60 |
|
Mental/Behavioral Health Services
|
$0 | $6 | $30 | $30 |
|
Imaging & Specialized Radiology
|
$50 | $400 | $700 | $700 |
|
Rehabilitative Services -ST, OT, PT
|
$10 | $30 | $60 | $60 |
|
Routine Laboratory Services
|
$5 | $20 | $45 | $45 |
|
Routine X-Ray & Diagnostic Services
|
$15 | $50 | $80 | $80 |
|
Prescription Drugs
|
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|
Tier 1 ? Preferred Generic Drugs
|
$0 | $5 | $20 | $29 |
|
Tier 2 ? Preferred Brand Drugs
|
$10 | $25 | $60 | $60 |
|
Tier 3 ? Non-Pref Brand & Generic Drugs
|
10% | 40% after ded | 40% after ded | 40% after ded |
|
Tier 4 ? Specialty Drugs
|
10% | 40% after ded | 40% after ded | 40% after ded |
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