<a style='color:rgb(255,255,255);font-size: 1em;'>2019 Freedom Plans</a>
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 $120 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 Drugs 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

  • Rx Coverage in the Gap
    Includes Rx Coverage in the Gap for Generic Drugs only: $3/$12/$0 (Tiers 1, 2, 6).

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

  • Dental Coverage
    The plan includes preventive and comprehensive dental coverage.

Material ID: Y0039_2019_SCPWebsite_M (CMS Accepted) Last Updated 11/09/2018