2015 Benefit Highlights - SCAN Plus (HMO)

SCAN PLUS | Benefit Highlights
For more information, contact your Authorized
SCAN Representative or call the number below:
3800 Kilroy Airport Way, Suite 100
Long Beach, CA 90806
SCAN Plus (HMO)
Sales Information :
1-877-807-7226
8 a.m. – 8 p.m., Monday through Friday, Pacific Time
(8 a.m. – 8 p.m., 7 days a week, Pacific Time, October 1
through February 14)
2015 Benefit Highlights
TTY Users : 711
— OR —
Visit our web site
www.scanhealthplan.com
SCAN Plus (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.
The benefit information provided herein is a brief summary, not a complete description of benefits. Benefits,
formulary, provider/pharmacy network, premium, co-payments and/or co-insurance may change on January 1 of
each year. Limitations, copayments, and restrictions may apply. For more information contact the plan. Calling the
agent number will direct you to a licensed insurance agent.
This information is available for free in other languages. Please call our customer service number at 1-800-559-3500,
8 a.m. – 8 p.m., seven days a week. TTY users call 711. Esta información está disponible gratuitamente en otros
idiomas. Llame a nuestro número de servicio al cliente 1-800-559-3500, 8 a.m. – 8 p.m., siete días a la semana.
Los usuarios de TTY deben llamar al 711. 本資訊亦免費提供其他語言版本。請撥打 1-800-559-3500 聯絡我們的
客戶服務部上午 8 時到晚上 8 時, 一週七天TTY 用戶請撥打 711.
Y0057_SCAN_8798_2014F File & Use Accepted 08272014
Los Angeles, Riverside, San Bernardino,
and San Francisco Counties
G8750 08/14 15C-BHL222
Comprehensive Care
Hospital and Emergency Care
SCAN PLUS
SCAN PLUS
SCAN PLUS
SCAN PLUS
Monthly Plan Premium
LA, RV, SB: $28.80*
SF: $26.80*
$0
Inpatient Hospital Care
Medicare fee-for-service costs
$0
Primary Care Office Visits
20%
$0
Skilled Nursing Facility
Medicare fee-for-service costs
$0
Specialist Office Visits
20%
$0
Outpatient Surgery
20%
$0
Diabetic Self-Management Training
20%
$0
Diabetic Supplies
(Lancets, Test Strips, Monitor)
20%
$0
Emergency Care
$65 (U.S. only)
$0 (U.S. only)
Urgent Care Services
20% (U.S. only)
$0 (U.S. only)
Annual Physical Exam
$0
$0
Preventive Services
(Medicare-Covered Screenings)
$0
$0
Ambulance Services
20% (per one-way trip)
$0 (per one-way trip)
Lab Services
$0
$0
Durable Medical Equipment
20%
$0
Diagnostic Tests and Procedures
20%
$0
X-rays
20%
$0
Diagnostic & Therapeutic Radiology
20%
$0
Outpatient Rehabilitation
20%
$0
Maximum Out of Pocket (MOOP)
$6,700
$6,700
(With Medicare Only)
(With Medicare &
Full Medi-Cal Eligiblity)
Prescription Drug Coverage
SCAN PLUS
(With Medicare Only)
SCAN PLUS
(With Medicare &
Full Medi-Cal Eligiblity)
Initial Coverage Stage – SCAN Contracted Pharmacy (1-month/31-Day Supply of Drugs)
Deductible
$320*
$0
Tier 1: Preferred Generic drugs
25%*
$0 or $1.20 or $2.65
Tier 2: Non-Preferred Generic drugs
25%*
$0 or $1.20 or $2.65
Tier 3: Preferred Brand drugs
25%*
$0 or $3.60 or $6.60
Tier 4: Non-Preferred Brand drugs
25%*
$0 or $3.60 or $6.60
Tier 5: Specialty drugs
25%*
$0 or $3.60 or $6.60
Tier 6: Select Care drugs
25%*
$0 or $3.60 or $6.60
*If you qualify for “Extra Help” with your prescription drug costs, the “Extra Help” program will pay all or part of your
monthly plan premium and your prescription drug deductibles and copays.
(With Medicare Only)
(With Medicare &
Full Medi-Cal Eligiblity)
Additional Benefits and Services
SCAN PLUS
SCAN PLUS
$0 (1 per year)
$0 (1 per year)
Glasses or Contacts Copay
LA, RV, SB: $0 (every two years)
SF: $25 (every two years)
LA, RV, SB: $0 (every two years)
SF: $25 (every two years)
Coverage for Frames or Contacts
$175 (every two years)
$175 (every two years)
$0 (1 per year)
$0 (1 per year)
$1,400 (every two years)
$1,400 (every two years)
Acupuncture and Chiropractic
Services (Routine)
$0 (10 visits per year
combined)
$0 (10 visits per year
combined)
Transportation (Routine)
LA, RV, SB:
$0 (22 one-way trips)
SF:
$0 (24 one-way trips)
LA, RV, SB:
$0 (22 one-way trips)
SF:
$0 (24 one-way trips)
Podiatry Services (Routine)
$0 (6 visits per year)
$0 (6 visits per year)
Health Club Membership
$0
$0
Home Delivered Meals
$0
criteria and limitations apply
$0
criteria and limitations apply
(With Medicare Only)
Vision Services (Routine)
Eye Exam
Hearing Services (Routine)
Hearing Exam
Coverage for Hearing Aids
(With Medicare &
Full Medi-Cal Eligiblity)
Comprehensive Care
Hospital and Emergency Care
SCAN PLUS
SCAN PLUS
SCAN PLUS
SCAN PLUS
Monthly Plan Premium
LA, RV, SB: $28.80*
SF: $26.80*
$0
Inpatient Hospital Care
Medicare fee-for-service costs
$0
Primary Care Office Visits
20%
$0
Skilled Nursing Facility
Medicare fee-for-service costs
$0
Specialist Office Visits
20%
$0
Outpatient Surgery
20%
$0
Diabetic Self-Management Training
20%
$0
Diabetic Supplies
(Lancets, Test Strips, Monitor)
20%
$0
Emergency Care
$65 (U.S. only)
$0 (U.S. only)
Urgent Care Services
20% (U.S. only)
$0 (U.S. only)
Annual Physical Exam
$0
$0
Preventive Services
(Medicare-Covered Screenings)
$0
$0
Ambulance Services
20% (per one-way trip)
$0 (per one-way trip)
Lab Services
$0
$0
Durable Medical Equipment
20%
$0
Diagnostic Tests and Procedures
20%
$0
X-rays
20%
$0
Diagnostic & Therapeutic Radiology
20%
$0
Outpatient Rehabilitation
20%
$0
Maximum Out of Pocket (MOOP)
$6,700
$6,700
(With Medicare Only)
(With Medicare &
Full Medi-Cal Eligiblity)
Prescription Drug Coverage
SCAN PLUS
(With Medicare Only)
SCAN PLUS
(With Medicare &
Full Medi-Cal Eligiblity)
Initial Coverage Stage – SCAN Contracted Pharmacy (1-month/31-Day Supply of Drugs)
Deductible
$320*
$0
Tier 1: Preferred Generic drugs
25%*
$0 or $1.20 or $2.65
Tier 2: Non-Preferred Generic drugs
25%*
$0 or $1.20 or $2.65
Tier 3: Preferred Brand drugs
25%*
$0 or $3.60 or $6.60
Tier 4: Non-Preferred Brand drugs
25%*
$0 or $3.60 or $6.60
Tier 5: Specialty drugs
25%*
$0 or $3.60 or $6.60
Tier 6: Select Care drugs
25%*
$0 or $3.60 or $6.60
*If you qualify for “Extra Help” with your prescription drug costs, the “Extra Help” program will pay all or part of your
monthly plan premium and your prescription drug deductibles and copays.
(With Medicare Only)
(With Medicare &
Full Medi-Cal Eligiblity)
Additional Benefits and Services
SCAN PLUS
SCAN PLUS
$0 (1 per year)
$0 (1 per year)
Glasses or Contacts Copay
LA, RV, SB: $0 (every two years)
SF: $25 (every two years)
LA, RV, SB: $0 (every two years)
SF: $25 (every two years)
Coverage for Frames or Contacts
$175 (every two years)
$175 (every two years)
$0 (1 per year)
$0 (1 per year)
$1,400 (every two years)
$1,400 (every two years)
Acupuncture and Chiropractic
Services (Routine)
$0 (10 visits per year
combined)
$0 (10 visits per year
combined)
Transportation (Routine)
LA, RV, SB:
$0 (22 one-way trips)
SF:
$0 (24 one-way trips)
LA, RV, SB:
$0 (22 one-way trips)
SF:
$0 (24 one-way trips)
Podiatry Services (Routine)
$0 (6 visits per year)
$0 (6 visits per year)
Health Club Membership
$0
$0
Home Delivered Meals
$0
criteria and limitations apply
$0
criteria and limitations apply
(With Medicare Only)
Vision Services (Routine)
Eye Exam
Hearing Services (Routine)
Hearing Exam
Coverage for Hearing Aids
(With Medicare &
Full Medi-Cal Eligiblity)
SCAN PLUS | Benefit Highlights
For more information, contact your Authorized
SCAN Representative or call the number below:
3800 Kilroy Airport Way, Suite 100
Long Beach, CA 90806
SCAN Plus (HMO)
Sales Information :
1-877-807-7226
8 a.m. – 8 p.m., Monday through Friday, Pacific Time
(8 a.m. – 8 p.m., 7 days a week, Pacific Time, October 1
through February 14)
2015 Benefit Highlights
TTY Users : 711
— OR —
Visit our web site
www.scanhealthplan.com
SCAN Plus (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.
The benefit information provided herein is a brief summary, not a complete description of benefits. Benefits,
formulary, provider/pharmacy network, premium, co-payments and/or co-insurance may change on January 1 of
each year. Limitations, copayments, and restrictions may apply. For more information contact the plan. Calling the
agent number will direct you to a licensed insurance agent.
This information is available for free in other languages. Please call our customer service number at 1-800-559-3500,
8 a.m. – 8 p.m., seven days a week. TTY users call 711. Esta información está disponible gratuitamente en otros
idiomas. Llame a nuestro número de servicio al cliente 1-800-559-3500, 8 a.m. – 8 p.m., siete días a la semana.
Los usuarios de TTY deben llamar al 711. 本資訊亦免費提供其他語言版本。請撥打 1-800-559-3500 聯絡我們的
客戶服務部上午 8 時到晚上 8 時, 一週七天TTY 用戶請撥打 711.
Y0057_SCAN_8798_2014F File & Use Accepted 08272014
Los Angeles, Riverside, San Bernardino,
and San Francisco Counties
G8750 08/14 15C-BHL222

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