Doctors & Hospitals Amount You Will Pay
PCP Office Visits $10
Specialist Office Visits $35
Emergency Room Care $120 per visit
Inpatient Hospital $250 / 4 days per period
Outpatient Hospital Services $250 per visit
Routine Lab Services $0
Diagnostic and X-Ray $50 / $75 / $100 per visit
Prescription Coverage Amount You Will Pay
Coverage in the Gap $3 / $12 / $0 (Tiers 1, 2, 6)
Preferred Generic-Tier 1 $3 (30-day)
Non-Preferred Generic-Tier 2 $12 (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 $3 / $12 / $0 (Tiers 1, 2, 6 only).

  • Dental Coverage
    Includes preventive and comprehensive dental coverage.

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

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

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

  • Durable Medical Equipment
    The plan pays 90% of the cost of in-network purchases of durable medical equipment like wheelchairs. If you choose a preferred vendor, your cost may be less.

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