|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|
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