|Doctors & Hospitals||Amount You Will Pay|
|PCP Office Visits||$15 per visit|
|Specialist Office Visits||$50 per visit|
|Inpatient Hospital||$325 / 5 days per period|
|Emergency Room Care||$120 per visit|
|Diagnostic and X-Ray||$90 / $125 / $160 per visit|
|Routine Lab Services||$0 per visit|
|Outpatient Hospital Services||$325 per visit|
|Prescription Coverage||Amount You Will Pay|
|Coverage in the Gap||Not Covered|
|Preferred Generic-Tier 1||$6 (30-day supply)|
|Non-Preferred Generic-Tier 2||$14 (30-day supply)|
|Preferred Brand-Tier 3||$47 (30-day supply)|
|Non-Preferred Brand-Tier 4||$100 (30-day supply)|
|Specialty Drugs-Tier 5||29% coinsurance|
|Select Care Drugs-Tier 6||$3 (30-day supply)|
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.
Includes a year-long gym membership at one of the participating fitness facilities.
Preventive Dental Coverage
The plan includes two annual preventive dental exams.
Material ID: Y0039_2019_SCPWebsite_M (CMS Accepted) Last Updated 11/09/2018