|Doctors & Hospitals||Amount You Will Pay|
|PCP Office Visits||$20 per visit|
|Specialist Office Visits||$50 per visit|
|Inpatient Hospital||$350 / 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||$350 per visit|
|Prescription Coverage||Amount You Will Pay|
|Coverage in the Gap||Not Covered|
|Preferred Generic-Tier 1||$8 (30-day supply)|
|Non-Preferred Generic-Tier 2||$16 (30-day supply)|
|Preferred Brand-Tier 3||$47 (30-day supply)|
|Non-Preferred Brand-Tier 4||$100 (30-day supply)|
|Specialty Drugs-Tier 5||28% coinsurance|
|Select Care Drugs-Tier 6||$4 (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.
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.
Includes a year-long gym membership at one of the participating fitness facilities.
Material ID: Y0039_2019_SCPWebsite_M (CMS Accepted) Last Updated 11/09/2018