Doctors & Hospitals Amount You Will Pay
PCP Office Visits $10 per visit
Specialist Office Visits $40 per visit
Inpatient Hospital $275 / 6 days per period
Emergency Room Care $75 per visit
Diagnostic and X-Ray $50 / $75 / $100 per visit
Routine Lab Services $0 per visit
Outpatient Hospital Services $275 per visit
Prescription Coverage Amount You Will Pay
Coverage in the Gap Generic and Select Care only $3/$12/$0 (Tiers 1, 2, 6)
Preferred Generic-Tier 1 $3 (30-day supply)
Non-Preferred Generic-Tier 2 $12 (30-day supply)
Preferred Brand-Tier 3 $47 (30-day supply)
Non-Preferred Brand-Tier 4 $100 (30-day supply)
Specialty Drugs-Tier 5 33% coinsurance
Select Care Drugs-Tier 6 $0 (30-day supply)

Plan highlights

  • 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.

  • Gym Membership
    Includes a year-long gym membership at one of the participating fitness facilities.

  • 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: Y0039_2018_SCPWebsite CMS Pending Last Updated 11/27/2017