Doctors & Hospitals Amount You Will Pay
PCP Office Visits $20
Specialist Office Visits $50
Routine Lab Services $0 per visit
Emergency Room Care $120 per visit
Inpatient Hospital $300 / 6 days per period
Outpatient Hospital Services $300 per visit
Diagnostic and X-Ray $70 / $105 / $140 per visit
Prescription Coverage Amount You Will Pay
Coverage in the Gap Not Covered
Preferred Generic-Tier 1 Not Covered
Non-Preferred Generic-Tier 2 Not Covered
Preferred Brand-Tier 3 Not Covered
Non-Preferred Brand-Tier 4 Not Covered
Specialty Drugs-Tier 5 Not Covered
90-Day Supply Not Covered

Plan highlights

  • Enhanced Preventive Care
    Includes a free annual wellness visit and a wide variety of vaccinations and preventive screenings (including cardiovascular and cancer) at no charge.

  • Teladoc Virtual Visits
    Access to board-certified doctors in all 50 states, 24/7, 365 days a year for a $0 copay.

  • Vision & Hearing Coverage
    Includes $45 annual hearing exam and two hearing aids per year; $699 / $999. Also includes routine vision coverage of $25 per exam - $150 allowance.

Material ID: H2960_SCPWebsite_2020 (CMS Accepted) Last Updated 05/04/2020
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