<a style='color:rgb(255,255,255);font-size:1.1em;'>2019 Value Plans</a>
Doctors & Hospitals Amount You Will Pay
PCP Office Visits $10 per visit
Specialist Office Visits $50 per visit
Inpatient Hospital $275 / 5 days per period
Emergency Room Care $90 per visit
Diagnostic and X-Ray $65 / $100 / $135 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 $5 (30-day)
Non-Preferred Generic-Tier 2 $16 (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

  • 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_2019_SCPWebsite_M (CMS Accepted) Last Updated 05/17/2019