| Silver Plan 2 Cost Sharing Reduction | Silver Plan 2 Cost Sharing Reduction | Silver Plan 2 Cost Sharing Reduction | Silver Plan | |
|---|---|---|---|---|
| Services | CSR 100 | CSR 150 | CSR 200 | 2/250 |
| 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) | $0 | $0 | $3,450 Comb. Med/Rx | $5,200 Comb. Med/Rx |
| Out-of-Pocket Max (Ind/Fam) | $1,200/$2,400 | $2,850/$5,700 | $6,700 / $13,400 | $8,150 / $16,300 |
| Drug Deductible (Ind/Fam) | $0/$0 | $0/$0 | Comb. w/ med | Comb. w/ med |
| Emergency Room Services | 25% | 40% | 40% after ded | 40% after ded |
| Hospital / Facility Services | ||||
| Inpatient Hospital | $300/day (max 2 copays) | $575/day (max 2 copays) | $900/day (max 2 copays) | $1,350/day (max 2 copays) |
| Skilled Nursing Facility Services | $300/day | $575/day | $900/day | $1,350/day |
| Hospital Physician Services | $10 | $30 | $40 | $65 |
| Outpatient Surgery Services | 25% | 40% | 40% after ded | 40% after ded |
| Outpatient Services | ||||
| Primary & Urgent Care Services | $0 | $10 | $20 | $30 |
| Specialist Services | $10 | $30 | $40 | $65 |
| Mental/Behavioral Health Services | $0 | $10 | $20 | $30 |
| Imaging & Specialized Radiology | 25% | 40% | 40% after ded | 40% after ded |
| Rehabilitative Services -ST, OT, PT | 25% | 40% | 40% after ded | 40% after ded |
| Routine Laboratory Services | $0 | $30 | $30 | $40 |
| Routine X-Ray & Diagnostic Services | 25% | 40% | 40% after ded | 40% after ded |
| Prescription Drugs | ||||
| Tier 1 – Preferred Generic Drugs | $0 | $10 | $20 | $25 |
| Tier 2 – Preferred Brand Drugs | $15 | $40 | $60 | $65 |
| Tier 3 – Non-Pref Brand & Generic Drugs | 25% | 40% | 40% after ded | 50% after ded |
| Tier 4 – Specialty Drugs | 25% | 40% | 40% after ded | 50% after ded |
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