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| Services | CSR 100 | CSR 150 | CSR 200 | 2/250 |
|---|---|---|---|---|
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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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Not Available | Not Available | Not Available | Not Available |
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Benefit & Cost Share Highlights
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Deductible (Ind/Fam)
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$0 | $0 | $3,450 Comb. Med/Rx |
$5,200 Comb. Med/Rx |
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Out-of-Pocket Max (Ind/Fam)
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$1,200/$2,400 | $2,850/$5,700 | $6,700 / $13,400 | $8,150 / $16,300 |
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Drug Deductible (Ind/Fam)
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$0/$0 | $0/$0 | Comb. w/ med | Comb. w/ med |
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Emergency Room Services
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25% | 40% | 40% after ded | 40% after ded |
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Hospital / Facility Services
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Inpatient Hospital
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$300/day (max 2 copays) |
$575/day (max 2 copays) |
$900/day (max 2 copays) |
$1,350/day (max 2 copays) |
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Skilled Nursing Facility Services
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$300/day | $575/day | $900/day | $1,350/day |
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Hospital Physician Services
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$10 | $30 | $40 | $65 |
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Outpatient Surgery Services
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25% | 40% | 40% after ded | 40% after ded |
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Outpatient Services
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Primary & Urgent Care Services
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$0 | $10 | $20 | $30 |
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Specialist Services
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$10 | $30 | $40 | $65 |
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Mental/Behavioral Health Services
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$0 | $10 | $20 | $30 |
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Imaging & Specialized Radiology
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25% | 40% | 40% after ded | 40% after ded |
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Rehabilitative Services -ST, OT, PT
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25% | 40% | 40% after ded | 40% after ded |
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Routine Laboratory Services
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$0 | $30 | $30 | $40 |
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Routine X-Ray & Diagnostic Services
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25% | 40% | 40% after ded | 40% after ded |
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Prescription Drugs
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Tier 1 ? Preferred Generic Drugs
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$0 | $10 | $20 | $25 |
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Tier 2 ? Preferred Brand Drugs
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$15 | $40 | $60 | $65 |
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Tier 3 ? Non-Pref Brand & Generic Drugs
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25% | 40% | 40% after ded | 50% after ded |
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Tier 4 ? Specialty Drugs
|
25% | 40% | 40% after ded | 50% after ded |
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