Doctors & Hospitals | Amount You Will Pay |
PCP Office Visits | $20 per visit |
Specialist Office Visits | $50 per visit |
Inpatient Hospital | $375 / 5 days per period |
Emergency Room Care | $120 per visit |
Diagnostic and X-Ray | $100 / $140 / $180 per visit |
Routine Lab Services | $0 per visit |
Outpatient Hospital Services | $375 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 |
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.
Material ID: Y0039_2019_SCPWebsite_M (CMS Accepted) Last Updated 11/09/2018