| Silver Plan 4 Cost Sharing Reduction | Silver Plan 4 Cost Sharing Reduction | Silver Plan 4 Cost Sharing Reduction | Silver Plan | |
|---|---|---|---|---|
| Services | CSR 100 | CSR 150 | CSR 200 | 4/250 |
| 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) | $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 | ||||
| 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 | ||||
| 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 | ||||
| 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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