| Silver Plan 1 Cost Sharing Reduction | Silver Plan 1 Cost Sharing Reduction | Silver Plan 1 Cost Sharing Reduction | Silver Plan | |
|---|---|---|---|---|
| Services | CSR 100 | CSR 150 | CSR 200 | 1/250 |
| 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 | YES | YES | YES | YES |
| Benefit and Cost Share Highlights | ||||
| 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 | ||||
| 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 | ||||
| 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 | ||||
| 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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