SCAN has a contract with the Federal Government. SCAN is a Medicare Advantage Prescription Drug Plan
(MAPD) offered by SCAN Health Plan, which is an HMO with Medicare Advantage contracts. Co-payments
apply for most services. Limitations and Exclusions may apply. H5425_SCAN_3858_2008_CMS102008
| Classic |
Benefits & Services In Network |
Signature |
| $0 per month |
Monthly Plan Premium |
$59 per month |
$10 copay per PCP
$25 copay per Specialist |
Doctor Office Visits |
$10 copay per PCP
$25 copay per Specialist |
| $0 copay |
Inpatient Hospital Care |
$0 copay |
| $0 copay |
Skilled Nursing Facility |
$0 copay |
| $50 each visit |
Emergency Care Worldwide Coverage |
$50 each visit |
| $100 each visit |
Outpatient Surgery |
$200 each visit |
| $100 copay |
Ambulance |
$100 copay |
| $0 copay |
Transportation (limitations apply) |
$0 copay |
| $0 copay |
Diagnostic Tests, X-Rays and Lab Services |
$0 copay |
| 20% of cost for Medicare covered items |
Medical Supplies & Equipment |
20% of cost for Medicare covered items |
| $0 copay |
Health Club Membership |
$0 copay |
| $25 copay for Medicare covered visits |
Chiropractic Coverage |
$25 copay for Medicare covered visits |
$10 copay for exam
$0 - $10 copay for hearing aid fitting/evaluation
$400 limit for hearing aids every three years
|
Hearing Aid Services |
$10 copay for exam
$0 - $10 copay for hearing aid fitting/evaluation
$400 limit for hearing aids every three years
|
$10 copay for annual exam
$25 copay for glasses/contacts every two years
Coverage toward eyewear: $75 frames / $100 contacts
|
Vision Services |
$10 copay for annual exam
$25 copay for glasses/contacts every two years
Coverage toward eyewear: $75 frames / $100 contacts
|
| Included |
Healthwise® For Life Handbook |
Included |
| Included |
SCAN Club Newsletter |
Included |
| Included |
Friends and Family Program |
Included |
| Included |
SCAN OnCall® 24 Hour Nurse Line |
Included |
SCAN offers unique in-home services to facilitate recovery from an illness or injury. Coverage is provided up to $1,000 per calendar year. Authorization rules apply. Contact SCAN for details.
| Classic |
Benefits & Services In Network |
Signature |
| You pay $0 |
Home Delivered Meals |
You pay $0 |
| You pay $15 per visit |
Personal Care |
You pay $15 per visit |
| You pay $15 per visit |
Transportation Escort |
You pay $15 per visit |
| You pay $0 |
In-Home Recovery Benefit Coordinator |
You pay $0 |
| You pay $0 |
Custodial Level Care |
You pay $0 |
| Classic |
Benefits & Services In Network |
Signature |
$0 copay for Select Generic Drugs
$7 copay for Preferred Generic Drugs
$28 copay for Brand Drugs
$50 copay for Additional Brand Drugs
25% copay for Specialty Drugs
|
SCAN Contracted Pharmacy
1-month/31-Day
Supply of Drugs
|
$0 copay for Select Generic Drugs
$5 copay for Preferred Generic Drugs
$28 copay for Brand Drugs
$50 copay for Additional Brand Drugs
25% copay for Specialty Drugs
|
$0 copay for Select Generic Drugs
$14 copay for Preferred Generic Drugs
$56 copay for Brand Drugs
$100 copay for Additional Brand Drugs
|
SCAN Mail Order Service
3-month/90-Day
Supply of Drugs
|
$0 copay for Select Generic Drugs
$10 copay for Preferred Generic Drugs
$56 copay for Brand Drugs
$100 copay for Additional Brand Drugs
|
$2,800 in Total Drug Costs
After $2,800 Formulary
Generic Drugs Covered Copays Apply
Brand Drugs Not Covered
|
Coverage Limits |
$3,000 in Total Drug Costs
After $3,000 Formulary
Generic Drugs Covered Copays Apply
Brand Drugs Not Covered
|