Doctors & Hospitals Amount You Will Pay
PCP Office Visits $10 per visit
Specialist Office Visits $50 per visit
Inpatient Hospital $275 / 6 days per period
Emergency Room Care $80 per visit
Diagnostic and X-Ray $70 / $105 / $140 per visit
Routine Lab Services $0 per visit
Outpatient Hospital Services $275 per visit
Prescription Coverage Amount You Will Pay
Coverage in the Gap Not Covered
Preferred Generic-Tier 1 $6 (30-day supply)
Non-Preferred Generic-Tier 2 $16 (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
Specialty Drugs-Tier 6 $3 (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.

  • Hearing & Vision
    Includes $45 annual hearing exam and two hearing aids per year; $699 / $999. Also includes routine vision coverage of $25 per exam - $150 allowance.

  • Durable Medical Equipment
    The plan pays 80% 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