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 |
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