2019 Benefit Highlights - NEW PLAN - ENGLISH
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Los Angeles County 2019 Benefit Highlights NEW PLAN SCAN Prime (HMO) Medicare Advantage Plan FEATURED BENEFITS • Over-the-Counter Drugs • VIAGRA (generic) • Telehealth • Dental Coverage Included
Plan Details SCAN PRIME
Monthly Plan Premium $25
Annual Plan Deductible $0
Comprehensive Care SCAN PRIME
Primary Care Office Visits $0
Specialist Office Visits $0
Diabetic Self-Management Training $0
Diabetic Supplies
$0
(lancets, test strips, monitor)
Annual Physical Exam $0
Preventive Services
$0
(Medicare-covered screenings)
Lab Services and X-rays $0
Diagnostic Tests and Procedures $0
Durable Medical Equipment $0
Outpatient Rehabilitation
$0
(e.g. PT, OT, ST)
Diagnostic Radiology
$50
(e.g. MRI, CT)
Hospital and Emergency Care SCAN PRIME
$0 per day
Inpatient Hospital Care
unlimited days
$0 per day (days 1−20)
Skilled Nursing Facility
$50 per day (days 21−100)
Outpatient Surgery $0
$90 (worldwide)
Emergency Care
$0 (if admitted immediately)
Urgent Care Services $0 (worldwide)
Ambulance Services $200
Maximum Out-of-Pocket SCAN PRIME
Annual Maximum Out-of-Pocket (MOOP) $1,200
Prescription Drug Coverage SCAN PRIME
Pharmacy Network Preferred Standard
Part D Deductible $0 $0
Initial Coverage Stage - SCAN Contracted Retail Pharmacy (1-month/30-day supply)
TIER 1: Preferred Generic $0 $5
TIER 2: Generic $5 $12
TIER 3: Preferred Brand $42 $47
TIER 4: Non-Preferred Drug $95 $100
TIER 5: Specialty Tier 33% 33%
Coverage Gap Tiers 1 & 2 Tiers 1 & 2
Savings Opportunities
For greatest savings, get a 3-month (90-day) supply of Tier 1 and Tier 2 drugs at Express
Scripts Mail-Order for $0.
Or fill a 3-month (90-day) supply of Tier 1 and Tier 2 drugs at your local retail pharmacy
and pay for only 2 months.
What Are “Additional Benefits and Services”?
“Additional Benefits” are benefits and services not offered by Original Medicare. These services do not need
a referral from your doctor.Additional Benefits and Services SCAN PRIME
Vision Services (routine)
Eye exam $0 (1 per year)
Glasses or contact lenses $30 (every 2 years)
Coverage for frames or contacts $175 (every 2 years)
Transportation (routine) $0 (up to 24 one-way trips per year)*
Health Club Membership $0
Generic Viagra
Tier 2 copay—maximum 4 tablets per month
(Sildenafil tabs 25 mg, 50 mg, 100 mg)
Acupuncture and Chiropractic Services $0 per visit
(routine) (20 visits per year combined)
Podiatry Services (routine) $0 (6 visits per year)
Dental Services (routine)
Dental exams $13
Dental cleanings $15 (1 every 6 months)
Dental X-rays $15 (1 every 6 months)
Hearing Services (routine)
Hearing exam $0 (1 per year)
Hearing aid copay $699/$999 (per aid/per year)
$50 quarterly allowance
Over-the-Counter (OTC)
(for items ordered through SCAN’s OTC mail-order catalog)
Telehealth $40 virtual office visit (telephonic or video)
$0 personal in-home care visits (bathing, dressing, etc.)
Returning to Home
$0 home delivered meals
(criteria & limitations apply)
$0 telephonic personal support services
* 75-mile limit will apply to each one-way tripThe SCAN Story SCAN, a not-for-profit health plan, was founded in 1977 by seniors, for seniors. More than forty years later, seniors are still at the heart of all we do. You can count on SCAN to keep you healthy and independent for years to come. That’s been our mission since day one. SCAN Prime (HMO) SCAN Prime (HMO) is SCAN’s newest plan offering. It includes all the same popular benefits as our Classic Plan such as comprehensive medical, hospital and pharmacy coverage. SCAN Prime offers the widest array of benefits, like a gym membership, dental, vision, hearing aids, plus even more enhanced coverage and benefits not included in Original Medicare.
Contact an authorized SCAN
representative today
1-877-807-7226
Or visit:
www.scanhealthplan.com
TTY users: 711
8 a.m. to 8 p.m., Monday through Friday, Pacific Time
8 a.m. to 8 p.m., 7 days a week, Pacific Time
(From October 1 through March 31)
SCAN Prime (HMO) is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan
depends on contract renewal. You must continue to pay your Medicare Part B premium.
This information is not a complete description of benefits. Call 1-877-807-7226 (TTY: 711) for more
information. Calling the agent number will direct you to a licensed insurance agent.
You can get prescription drugs shipped to your home through our network mail-order delivery program
which is called Express Scripts Home Delivery. Typically, you should expect to receive your prescription
drugs within 14 days from the time that the mail-order pharmacy receives the order. If you do not receive
your prescription drug(s) within this time, please contact SCAN Health Plan Member Services.
SCAN Health Plan complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability or sex.
ATTENTION: If you speak another language, language assistance services, free of charge, are available
to you. Call 1-800-559-3500. (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios
gratuitos de asistencia lingüística. Llame al 1-800-559-3500. (TTY: 711). 注意：如果您使用中文，您
可以免費獲得語言援助服務。請致電 1-800-559-3500。（聽障專線：711）。
Y0057_SCAN_10870_2018F_M_08212018 R562 08/18 19C-BHL900You can also read
