SCAN® is a Medicare Advantage Prescription Drug Plan (MAPD) offered by SCAN Health Plan, which is an HMO with Medicare Advantage contracts. Limitations and Exclusions may apply.
H5425_SCAN_3174-2007_CMS092807

Monthly Plan Premium	$0 per month
Doctor Office Visits	$10 copay $25 copay for Specialist
Inpatient Hospital Care	$0 copay
Skilled Nursing Facility 100 days limit per benefit period	$0 each day
Worldwide Emergency Care (waived if admitted to hospital)	$50 each visit
Outpatient Surgery At an ambulatory surgical center or outpatient hospital facility	$100 each visit
Ambulance Medicare covered	$100 copay
Transportation 12 one-way rides (6 round trips) per year in a passenger vehicle or wheelchair van to contracted medical providers	$0 copay
Eye Exam Yearly routine and preventive eye care services; Glasses/contacts are covered every two calendar years	$10 copay for exam $25 copay for glasses/contacts $100 coverage toward eyewear $130 coverage toward contacts
Hearing Aid Services Coverage up to $200 per hearing aid, or $400 for two aids, every three calendar years	$0 - $10 copay for exam $0 - $10 copay for hearing aid fitting/evaluation.
Diagnostic Tests, X-Rays and Lab Services For specialized scans such as CT, SPECT, MRI, MRA, Myelogram, Cystogram, Angiogram and certain diagnostic nuclear scans, you pay 20%	$0 copay
Medical Supplies & Equipment	20% of what Medicare pays

SCAN Coverage up to $2,600 in total drug costs
SCAN Contracted Pharmacy	SCAN Mail Order Service
1- Month/31-Day Supply of Drugs	3- Month/90-Day Supply of Drugs
$7 copay for Formulary Generic Drugs $28 copay for Formulary Brand Drugs $50 copay for Formulary Additional Brand Drugs 25% copay for Formulary Specialty Drugs	$14 copay for Formulary Generic Drugs $56 copay for Formulary Brand Drugs $100 copay for Formulary Additional Brand Drugs
Coverage After $2,600 in Total Drug Costs $10 copay for Formulary Generic Drugs – Brand Drugs not covered
If You Reach $4,050 in Member Out-of-Pocket Costs
You pay a $2.25 copay for generic or preferred brand drugs and $5.60 copay for all other drugs, or 5% of the drug cost, whichever is greater

Assistance 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

SCAN offers unique in-home services to facilitate recovery from an illness or injury and/or to decrease the incidence of future occurrences. Coverage is provided up to $1,000 per calendar year following a discharge from a hospital, skilled nursing facility or emergency room. Services must be initiated within the first 30 days of discharge and are available for up to 90 days from the start of the service(s). Authorization rules apply. Contact SCAN for details.

Available In-Home Recovery benefits include:

Home Delivered Meals You are covered for home delivery of frozen meals to meet caloric or dietary needs based on a medical condition or to provide nutrition if you are injured or disabled (example – recovery from a stroke).	You pay $0
Personal Care You are covered for in-home assistance during your recovery for tasks such as bathing, dressing, toileting, meal preparation, and bed linen changes to protect skin integrity.	You pay $15 per visit
Transportation Escort As a SCAN member you are eligible to receive an escort to assist you during transportation to and from post-discharge medical appointments.	You pay $15 per visit
In-Home Recovery Benefit Coordinator SCAN staff will provide personal assistance to coordinate your In-Home Recovery benefits.	You pay $0
Custodial Level Care You are covered for up to three days of post acute support while staying in an in-patient facility such as a skilled nursing facility following a hospital discharge.	You pay $0