SCAN® is a Medicare Advantage Prescription Drug Plan (MAPD) offered by SCAN Health Plan, which is a Special Needs Plan and an HMO with Medicare Advantage contracts. Limitations and Exclusions may apply. H9104_H5425_SCAN_3173-2007_DHS102607

Monthly Plan Premium	$0 per month
Doctor Office Visits PCP or Specialist visits	$0 copay per visit
Inpatient Hospital Care	$0 per day
Worldwide Emergency Care	$0 each visit
Outpatient Surgery At an ambulatory surgical center or outpatient hospital facility	$0 each visit
Ambulance Medicare covered	$0 copay
Transportation Passenger car or wheelchair van rides to SCAN medical providers. Rides to contracted providers only. Authorization rules apply. No Limit to the number of rides you can have.	$0 copay
Routine Podiatry Up to 6 visits per year for self-referred routine care (Los Angeles County only)	$0 copay
Eye Exam Yearly routine and preventive eye care services; Medi-cal covered glasses/contacts are covered every calendar year	$0 copay for exam $0 copay for glasses/contacts
Hearing Aid Services Two Medi-Cal covered hearing aids every 2 calendar years	$0 copay
Diagnostic Tests, X-Rays and Lab Services	$0 copay
Durable Medical Supplies & Equipment 100% Coverage when purchased at a Plan (Medical equipment) provider location	$0 copay
Preventive Dental Services 100% Coverage for annual exams and cleanings. Maximum of two cleaning visits in a 12 month period	$0 copay
Chiropractic Care You are covered for Medicare covered chiropractic care. Manual adjustment of the spine to correct a subluxation. (dislocation of the spine) A referral from your primary care physician is required.	$0 copay
Acupuncture Maximum of two office visits per month	$0 copay

Unlimited Coverage for Drug Costs
SCAN Contracted Pharmacy	SCAN Contracted Pharmacy Mail Order Service
1- Month/31-Day Supply of Drugs*	3- Month/90-Day Supply of Drugs
$1.05 or $2.25 copay for Formulary Generic Drugs $3.10 or $5.60 copay for Formulary Brand Drugs $3.10 or $5.60 copay for Formulary Additional Brand Drugs $3.10 or $5.60 copay for Formulary Specialty Drugs	$1.05 or $2.25 copay for Formulary Generic Drugs $3.10 or $5.60 copay for Formulary Brand Drugs $3.10 or $5.60 copay for Formulary Additional Brand Drugs
If You Reach $4,050 in Member Out-of-Pocket Costs (No Copayment)
*Drug copay amounts depend on income limits that are tied to Federal poverty guidelines that are updated annually. If your annual income is below $10,210 ($13,690 couple) you will have copays of $1.05 (generic) or $3.10 (brand). If your annual income is above $10,210 ($13,690 couple) you will have copays of $2.25 (generic) or $5.60 (brand). Values shown reflect Federal poverty guidelines published in January 2007.

Help at your fingertips
Sales Information 8am – 8pm, 7 days per week 1-800-915-7226	TTY Users 7am – 8pm, 7 days per week 1-800-735-2929

Independent Living Power services will help a member remain safely at home. An ILP Specialist will arrange for in-home help when friends and family are not enough. Members can receive all Independent Living Power services at no cost to them.

Independent Living Power services are only for certain members. These members must need the same level of care as someone in a nursing home.

Independent Living Power services include:

ILP Specialist Organizes the appropriate care for each individual plan member	$0 copay
Personal Care Assistance with bathing, dressing, eating, toileting, getting in and out of bed, moving about/walking and grooming	$0 per visit
Homemaker Services Light house cleaning, grocery shopping, laundry and meal preparation	$0 per visit
Emergency Response System A personal device that alerts emergency medical personnel to provide immediate help	$0 per month
Transportation Passenger car or wheelchair van rides to SCAN medical providers. Rides to contracted providers only. Authorization rules apply. No Limit to the number of rides you can have.	$0 copay
Transportation Escort Accompanies a member to contracted medical appointments	$0 per visit
Home-Delivered Meals Nutritious meals delivered to your home	$0 per meal
Caregiver Relief When your regular family caregiver is unavailable, you may receive: An alternate caregiver when your regular family caregiver is not available Up to five days in a facility to provide relief for your family caregiver You also may receive Adult Day Care. This is a center where you can go for a few hours or for the day. Activities are provided for your enjoyment.	$0 copay
Social DME Items not covered by Medicare, such as bath benches and grab bars to increase bathroom safety.	$0 copay

You must qualify for Independent Living Power benefits.