<a style='color:rgb(255,255,255);font-size:1.1em;'>2019 Value Rx <br>Complete HMO</a>
Doctors & Hospitals Amount You Will Pay
PCP Office Visits $0 per visit
Specialist Office Visits $0 per visit
Inpatient Hospital $0 per day
Emergency Room Care $120 per visit
Diagnostic and X-Ray $0 / $50 / $200 per visit
Routine Lab Services $0 per visit
Outpatient Hospital Services $0 per visit
Prescription Coverage Amount You Will Pay
Coverage in the Gap $2 / $8 / $0 (Tiers 1, 2, 6)
Preferred Generic-Tier 1 $2 (30 day) [$0 mail]
Non-Preferred Generic-Tier 2 $8 (30 day)
Preferred Brand-Tier 3 $47 (30-day)
Non-Preferred Brand-Tier 4 $100 (30-day)
Specialty Drugs-Tier 5 33% coinsurance
90-Day Supply 2.5 times 30-day

Plan highlights

  • Rx Coverage in the Gap
    Includes Rx Coverage in the Gap for Generic Drugs only: $2/$8/$0 (Tiers 1, 2, 6).

  • Hearing & Vision
    Includes $0 annual hearing exam and two hearing aids per year; $299 / $599. Also includes routine vision coverage of $0 per exam - $150 allowance.

  • Gym Membership
    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