Doctors & Hospitals Amount You Will Pay
PCP Office Visits $0
Specialist Office Visits $0
Emergency Room Care $120 per visit
Inpatient Hospital $0 per day
Outpatient Hospital Services $0 per visit
Routine Lab Services $0
Diagnostic and X-Ray $0 / $50
Prescription Coverage Amount You Will Pay
Coverage in the Gap $2 / $8 / $0 (Tiers 1, 2, 6)
Preferred Generic-Tier 1 $2 (30-day) [$0 mail]
Non-Preferred Generic-Tier 2 $8 (30-day)
Preferred Brand-Tier 3 $47 (30-day
Non-Preferred Brand-Tier 4 $100 (30-day)
Specialty Drugs-Tier 5 33% coinsurance
90-Day Supply Retail 2.5 times 30-day

Plan highlights

  • Rx Coverage in the Gap
    Rx Coverage in the Gap for Generic Drugs only: $2/$8/$0 (Tiers 1, 2, 6).

  • Teladoc Virtual Visits
    24/7 access to Teladoc's board-certified doctors by phone or video in all 50 states for a $0 copay.

  • Over-the-Counter Benefit
    Receive a $50 quarterly over-the-counter benefit at the pharmacy.

  • Rx 90-day Mail
    Receive a 90-day refill for 2 times the price of a 30-day supply per tier.

  • Hearing & Vision
    $0 annual hearing exam and two hearing aids per year; $299 / $599. Routine vision coverage of $0 per exam - $150 allowance.

  • Fitness Benefit
    Year-long gym membership at one of the participating fitness facilities.

Material ID: H2960_SCPWebsite_2020 (CMS Accepted) Last Updated 1/03/2020
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