| Silver Plan 7 Cost Sharing Reduction | Silver Plan 7 Cost Sharing Reduction | Silver Plan 7 Cost Sharing Reduction | Silver Plan | |
|---|---|---|---|---|
| Services | CSR 100 | CSR 150 | CSR 200 | 7/250 |
| 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 | $0 / $0 | $0 / $0 | $0 / $0 |
| Out-of-Pocket Max (Ind/Fam) | $1,200 / $2,400 | $2,850 / $5,700 | $6,800 / $13,600 | $8,550 / $17,100 |
| Drug Deductible (Ind/Fam) | $0 / $0 | $80 / $160 Rx Tiers 3&4 Only | $350 / $700 Rx Tiers 3&4 Only | $1,350 / $2,700 Rx Tiers 3&4 Only |
| Emergency Room Services | $250 | $600 | $750 | $1,250 |
| Hospital / Facility Services | ||||
| Inpatient Hospital | $200/day (max 2 copays) | $375/day (max 2 copays) | $600/day (max 2 copays) | $600/day (max 2 copays) |
| Skilled Nursing Facility Services | $200/day | $375/day | $600/day | $600/day |
| Hospital Physician Services | $10 | $30 | $75 | $90 |
| Outpatient Surgery Services | $120 | $120 | $150 | $150 |
| Outpatient Services | ||||
| Primary & Urgent Care Services | $0 | $5 | $25 | $30 |
| Specialist Services | $10 | $30 | $75 | $90 |
| Mental/Behavioral Health Services | $0 | $5 | $25 | $30 |
| Imaging & Specialized Radiology | $100 | $400 | $700 | $700 |
| Rehabilitative Services -ST, OT, PT | $10 | $40 | $60 | $60 |
| Routine Laboratory Services | $20 | $30 | $50 | $50 |
| Routine X-Ray & Diagnostic Services | $30 | $60 | $100 | $135 |
| Prescription Drugs | ||||
| Tier 1 – Preferred Generic Drugs | $0 | $8 | $25 | $30 |
| Tier 2 – Preferred Brand Drugs | $10 | $35 | $75 | $100 |
| Tier 3 – Non-Pref Brand & Generic Drugs | 10% | 10% after Rx ded | 40% after Rx ded | 40% after Rx ded |
| Tier 4 – Specialty Drugs | 10% | 10% after Rx ded | 40% after Rx ded | 40% after Rx ded |
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