| 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
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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