| Services | CSR 100 | CSR 150 | CSR 200 | 4/250 |
|---|---|---|---|---|
|
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
|
Not Available | Not Available | Not Available | Not Available |
|
Benefit & Cost Share Highlights
|
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|
Deductible (Ind/Fam)
|
$725 Comb. Med/Rx |
$2,150 Comb. Med/Rx |
$5,975 Comb. Med/Rx |
$7,450 Comb. Med/Rx |
|
Out-of-Pocket Max (Ind/Fam)
|
$725 / $1,450 | $2,150 / $4,300 | $5,975/ $11,950 | $7,450 / $14,900 |
|
Drug Deductible (Ind/Fam)
|
Comb. w/Med | Comb. w/Med | Comb. w/ med | Comb. w/ med |
|
Emergency Room Services
|
0% after ded | 0% after ded | 0% after ded | 0% after ded |
|
Hospital / Facility Services
|
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|
Inpatient Hospital
|
$100/day (max 2 copays) |
$400/day (max 2 copays) |
$1,200/day (max 2 copays) |
$1,500/day (max 2 copays) |
|
Skilled Nursing Facility Services
|
$100/day | $400/day | $1,200/day | $1,500/day |
|
Hospital Physician Services
|
$10 | $30 | $60 | $65 |
|
Outpatient Surgery Services
|
0% after ded | 40% | 0% after ded | 0% after ded |
|
Outpatient Services
|
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|
Primary & Urgent Care Services
|
$0 | $7 | $20 | $30 |
|
Specialist Services
|
$10 | $30 | $60 | $65 |
|
Mental/Behavioral Health Services
|
$0 | $7 | $20 | $30 |
|
Imaging & Specialized Radiology
|
0% after ded | 0% after ded | 0% after ded | 0% after ded |
|
Rehabilitative Services -ST, OT, PT
|
0% after ded | 0% after ded | 0% after ded | 0% after ded |
|
Routine Laboratory Services
|
0% after ded | 0% after ded | 0% after ded | 0% after ded |
|
Routine X-Ray & Diagnostic Services
|
25% | 0% after ded | 0% after ded | 40% after ded |
|
Prescription Drugs
|
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|
Tier 1 ? Preferred Generic Drugs
|
$0 | $6 | $12 | $25 |
|
Tier 2 ? Preferred Brand Drugs
|
$20 | $50 | $70 | $75 |
|
Tier 3 ? Non-Pref Brand & Generic Drugs
|
0% after ded | 0% after ded | 0% after ded | 0% after ded |
|
Tier 4 ? Specialty Drugs
|
0% after ded | 0% after ded | 0% after ded | 0% after ded |
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