SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan
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Orange County SCAN Classic (HMO) SCAN Prime (HMO) SCAN Balance (HMO SNP) 2020 Benefit Highlights Medicare Advantage Plan
Plan Details SCAN Classic SCAN Prime SCAN Balance
Monthly Plan Premium $0 $26 $0
Annual Plan Deductible $0 $0 $0
Comprehensive Care SCAN Classic SCAN Prime SCAN Balance
Primary Care Office Visits $0 $0 $0
Specialist Office Visits $0 $0 $0
Diabetic Self-Management Training $0 $0 $0
Diabetic Supplies
$0 $0 $0
(lancets, test strips, monitor)
Annual Physical Exam $0 $0 $0
Preventive Services
$0 $0 $0
(Medicare-covered screenings)
Lab Services and X-rays $0 $0 $0
Diagnostic Tests and Procedures $0 $0 $0
Outpatient Rehabilitation
$0 $0 $0
(e.g. PT, OT, ST)
Diagnostic Radiology
$0 $0 $0
(e.g. MRI, CT, ultrasound)
Durable Medical Equipment $0–20% $0–20% $0
Hospital and Emergency
SCAN Classic SCAN Prime SCAN Balance
Care
$0 per day $0 per day $0 per day
Inpatient Hospital Care
unlimited days unlimited days unlimited days
$0 per day $0 per day $0 per day
(days 1−20) (days 1−20) (days 1−20)
Skilled Nursing Facility
$50 per day $50 per day $50 per day
(days 21−100) (days 21−100) (days 21−100)
Outpatient Surgery $0 $0 $0
$90 (worldwide) $90 (worldwide) $90 (worldwide)
Emergency Care $0 (if admitted $0 (if admitted $0 (if admitted
immediately) immediately) immediately)
Urgent Care Services $0 (worldwide) $0 (worldwide) $0 (worldwide)
Ambulance Services $100 $100 $200
Maximum Out-of-Pocket SCAN Classic SCAN Prime SCAN Balance
Annual Maximum Out-of-Pocket
$899 $800 $899
(MOOP)
Prescription Drug
SCAN Classic SCAN Prime SCAN Balance
Coverage
PHARMACY NETWORK PREFERRED STANDARD PREFERRED STANDARD PREFERRED STANDARD
Part D Deductible $0 $0 $0 $0 $0 $0
Initial Coverage Stage - SCAN Contracted Retail Pharmacy (1-month/30-day supply)
TIER 1: Preferred Generic $0 $7 $0 $5 $0 $5
TIER 2: Generic $5 $15 $5 $12 $2 $9
TIER 3: Preferred Brand $42 $47 $42 $47 $30 $35
TIER 4: Non-Preferred Drug $95 $100 $95 $100 $95 $100
TIER 5: Specialty Tier 33% 33% 33% 33% 33% 33%
Tiers 1 Tiers 1
and 2 and 2
Tiers Tiers Tiers Tiers
Coverage Gap
1 and 2 1 and 2 1 and 2 1 and 2 Tier 3 Tier 3
(insulin (insulin
only) only)
More Ways to Save on Prescriptions
Pay $0 for a 3-month supply for Tiers 1 and 2 through Express Scripts Mail Order pharmacy
OR pay for 2 months when you get a 3-month supply for Tiers 1 and 2 at your local retail pharmacy.
Optional Supplemental
SCAN Classic SCAN Prime SCAN Balance
Monthly Plan Premium
Essential Dental Plan $10 Not Available $10
Included extras you get with SCAN
SCAN provides these services and programs to help our members lead healthier,
more independent lives.
Core Extras SCAN Classic SCAN Prime SCAN Balance
Vision Services (routine)
Eye exam $0 (1 every 12 months) $0 (1 every 12 months) $0 (1 every 12 months)
Glasses or contact lenses $30 (every 24 months) $30 (every 24 months) $30 (every 24 months)
Coverage for frames or $175 (every 24 months) $175 (every 24 months) $175 (every 24 months)
contacts
Dental Services (routine)
Dental exams $0 (2 visits every $10 (2 visits every $0 (2 visits every
Cleaning 12 months) 12 months) 12 months)
Deep cleaning $0 (2 visits every $5 (2 visits every $0 (2 visits every
12 months) 12 months) 12 months)
$0 (per quadrant – $0 (per quadrant – $0 (per quadrant –
4 per year) 4 per year) 4 per year)
Transportation (routine)* $0 $0 $0
(24 one-way trips per year) (24 one-way trips per year) (30 one-way trips per year)
Non-medical trips to: Not Available Not Available 14 of the 30 trips
health club, grocery store,
or senior center
Health Club Membership $0 (SilverSneakers®) $0 (SilverSneakers®) $0 (SilverSneakers®)
Acupuncture, Chiropractic, $15 per visit $0 per visit $5 per visit
and Therapeutic Massage (30 visits/year combined) (20 visits/year combined) (unlimited)
Services (Acupuncture and (Acupuncture, Chiropractic, (Acupuncture and
Chiropractic only) and Therapeutic Massage) Chiropractic only)
Podiatry Services (routine) $0 (6 visits per year) $0 (6 visits per year) $0 (6 visits per year)
Hearing Services (routine)
Hearing exam $0 (1 per year) $0 (1 per year) $0 (1 per year)
Hearing aid copay or $450/$750 per aid/year $200/$400 per aid/year or $450/$750 per aid/year
Hearing aid allowance $3,000 for up to
2 hearing aids
Over-the-Counter (OTC) $30 allowance per quarter $50 allowance per quarter $30 allowance per quarter
Featured Extras SCAN Classic SCAN Prime SCAN Balance
Telehealth $0 per visit (telephonic or $0 per visit (telephonic or $0 per visit (telephonic or
Remote access to care virtual video visits) virtual video visits) virtual video visits)
Generic Viagra Tier 1 copay – Tier 1 copay – Not Available
(Sildenafil tabs 25 mg, 50 maximum 4 tablets maximum 4 tablets
mg, 100 mg) per month per month
FitbitTM Fitness Tracker $0 for the FitbitTM Inspire $0 for the FitbitTM Inspire Not Available
(1 Fitbit™ every 2 years) (1 Fitbit™ every 2 years)
SCAN Travel Assurance Benefit information for Benefit information for Benefit information for
Worldwide coverage unlimited urgent/emergent unlimited urgent/emergent unlimited urgent/emergent
worldwide coverage worldwide coverage worldwide coverage
*75-mile limit will apply to each one-way trip.
The SCAN Story
SCAN, a not-for-profit health plan, was founded in 1977 by seniors, for seniors. More than
forty years later, seniors are still at the heart of all we do. You can count on SCAN to keep
you healthy and independent for years to come. That’s been our mission since day one.
Solutions for Independence
In addition to the core benefits and extra services described inside,
SCAN Classic
SCAN knows that sometimes our members need a little more care to (HMO)
stay independent in their own homes for as long as possible, so we’ve SCAN Classic is our most
included these special benefits in your plan to help you do just that. competitive plan offering all the
benefits of Medicare and more.
SCAN Respite Care Services* Includes:
Providing a short-term break from the demands of
caregiving, SCAN offers respite care for full-time, unpaid
caregivers caring for SCAN members.
• Up to 40 hours per year (4-hour minimum per visit) in the
members’ home where the primary care giving takes place. SCAN Prime
SCAN Returning to Home* (HMO)
Extra help at home after a hospital stay can mean all the SCAN Prime includes all of
difference in your recovery. SCAN is there for you with: the benefits of SCAN Classic
— plus enhanced dental
•$ 0 Personal in-home care visits (bathing/dressing, etc.)
and over-the counter drug
up to 28 hours per year – 4-hour minimum per visit
• $0 Home delivered meals up to 28 days per year coverage, and the widest array
• $0 Telephonic personal support services of extra benefits.
Includes:
SCAN Home Advantage
As you age you want the confidence that your home can safely
support your changing needs. SCAN provides you with a:
• $0 cost in-home safety evaluation and
• $0 cost follow-up visit. SCAN Balance
Chronic Condition Meals* (HMO SNP)
Maintaining proper nutrition can help manage chronic SCAN Balance offers com-
health conditions. SCAN delivers on its promise to keeping prehensive medical coverage,
seniors healthy with $0 home delivered meals, for up to 28 lower-cost prescription options,
days per year. and more, to help you live with
and manage your diabetes.
Emergency Response System*
Includes:
Personal emergency response system that enables members
to remain at home, living safely and independently.
• $0 Installation and $0 monthly fee
*Criteria and limitations apply.
Contact an authorized SCAN
representative today
1-877-870- 4867
Or visit:
www.scanhealthplan.com
TTY users: 711
October 1 to March 31: 8 a.m. to 8 p.m.,
7 days a week
April 1 to September 30: 8 a.m. to 8 p.m.,
Monday through Friday
SCAN Classic (HMO), SCAN Prime (HMO) and SCAN Balance (HMO SNP) are HMO plans with Medicare
contracts. 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 1-877-870-4867 (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 PharmacySM. 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’s Member Services.
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_11582_2019F_M_08262019R1044 08/19 20C-BHL401
2020
Summary of Benefits
SCAN Classic (HMO)
and SCAN Prime (HMO)
Orange County
January 1, 2020 - December 31, 2020
SCAN Classic (HMO) and SCAN Prime (HMO) are HMO plans with a Medicare contract. Enrollment in SCAN
Health Plan depends on contract renewal.
The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get
a complete list of services we cover, please request the “Evidence of Coverage” by calling our Member Services
Department at the phone number listed in this document or online at www.scanhealthplan.com.
Y0057_SCAN_11544_2019F_MR1115 08/19 20C-SMB400SUMMARY OF BENEFITS JANUARY 1, 2020 – DECEMBER 31, 2020
PREMIUM AND BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW
Monthly Health Plan You pay $0 You pay $26 per You must continue to pay
Premium month your Medicare Part B
premium.
Deductible You pay $0 You pay $0 This plan does not have a
deductible.
Maximum Out-of-Pocket $899 annually $800 annually The most you pay for
Responsibility (this does copays and coinsurance for
not include prescription Medicare-covered medical
drugs) services for the year.
Inpatient Hospital Coverage You pay $0 You pay $0 Our plan covers an
unlimited number of days
for an inpatient hospital
stay. Prior authorization
rules apply.
Outpatient Hospital Prior authorization rules
Services apply for outpatient
hospital services.
• Ambulatory Surgical You pay $0 You pay $0
Center
• Outpatient Hospital You pay $0 You pay $0
Doctor Visits
• Primary Care You pay $0 You pay $0
• Specialists You pay $0 You pay $0 Prior authorization rules
apply for specialist visits.
Preventive Care You pay $0 You pay $0 Any additional preventive
services approved by
Medicare during the
contract year will be
covered. Prior authorization
rules apply.PREMIUM AND BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW
Emergency Care You pay $90 You pay $90 The emergency room
copay per visit copay per visit copay will be waived if you
are immediately admitted
to the hospital.
You are covered for
worldwide emergency
services.
Urgently Needed Services You pay $0 You pay $0 You are covered for
worldwide urgent care
services.
Diagnostic Services/Labs/ Prior authorization rules
Imaging apply for diagnostic, lab,
and imaging services.
• Lab services You pay $0 You pay $0
• Diagnostic tests and You pay $0 You pay $0
procedures
• Outpatient X-rays You pay $0 You pay $0
• Therapeutic radiology You pay $50 You pay $50
copay per visit copay per visit
• Diagnostic radiology You pay $0 You pay $0
(e.g., MRI, CT)PREMIUM AND BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW
Hearing Services
• Medicare-covered You pay $0 You pay $0 Prior authorization rules
diagnostic hearing and apply for Medicare-covered
balance exam diagnostic hearing and
balance exams.
• Non-Medicare-covered You pay $0 for You pay $0 for You must go to a SCAN-
(routine) hearing exam up to 1 visit every up to 1 visit every contracted provider to
12 months 12 months obtain a routine hearing
exam and hearing aids.
• Non-Medicare-covered You pay $450 Your benefit
(routine) hearing aids copay per aid includes 3 options:
for a TruHearing 1) A $200 copay
Advanced hearing per aid for
aid or $750 TruHearing
copay per aid Advanced
for a TruHearing hearing aids, or
Premium hearing
aid 2) a $400 copay
per aid for
You are covered TruHearing
for up to 2 hearing Premium
aids every 12 hearing aids,
months or
3) a $3,000
allowance
toward the
purchase of
any hearing
aid from the
TruHearing
Choice
product line.
You are covered
for up to 2 hearing
aids every 12
monthsPREMIUM AND BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW
Dental Services
• Medicare-covered You pay $0 You pay $0 Prior authorization rules
dental services apply for Medicare-covered
dental services.
• Non-Medicare-covered You pay $0 for up You pay $10 copay Routine dental benefits are
(routine) oral exam to 2 visits every 12 for up to 2 visits available with an additional
months every 12 months premium. See the
“Optional Supplemental
• Non-Medicare-covered You pay $0 for up You pay $5 copay Benefits” chart at the end
(routine) dental to 2 visits every 12 for up to 2 visits of this document.
cleaning months every 12 months
• Non-Medicare-covered You pay $0 for up You pay $15 copay
(routine) dental X-rays to 2 series every for up to 1 series
12 months every 6 months
Vision Services
• Medicare-covered You pay $0 You pay $0 Prior authorization rules
vision exam to apply for Medicare-covered
diagnose/treat diseases vision exam and glasses
of the eye after cataract surgery.
• Medicare-covered You pay $0 You pay $0
glasses after cataract
surgery
• Non-Medicare-covered You pay $0 for up You pay $0 for up Routine vision services
(routine) vision exam to 1 visit every 12 to 1 visit every 12 do not require a
months months prior authorization.
• Non-Medicare-covered You pay $30 copay You pay $30 copay You must go to a SCAN-
(routine) glasses or per pair every 24 per pair every 24 contracted vision provider
contact lenses months months to obtain routine vision
services.
• Non-Medicare-covered You are covered You are covered
(routine) vision for up to $175 for for up to $175 for
coverage limit frames or contact frames or contact
lenses every 24 lenses every 24
months monthsPREMIUM AND BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW
Mental Health Services
• Inpatient visit You pay $0 per You pay $0 per Prior authorization rules
day for days 1-90 day for days 1-90 apply for inpatient mental
health hospitalization. You
are covered for up to 90
days per benefit period.*
• Outpatient individual/ You pay $0 You pay $0 Prior authorization rules
group therapy visit apply for outpatient mental
health services.
• Outpatient individual/ You pay $0 You pay $0
group therapy visit with
a psychiatrist
Skilled Nursing Facility You pay $0 per You pay $0 per Prior authorization rules
day for days 1-20 day for days 1-20 apply for skilled nursing
facility services. You are
You pay $50 You pay $50 covered for up to 100 days
copay per day for copay per day for per benefit period.*
days 21-100 days 21-100
No prior hospitalization is
required.
Physical Therapy You pay $0 You pay $0 Prior authorization rules
apply for outpatient
physical therapy services.
Ambulance You pay $100 You pay $100
copay per one-way copay per one-way
trip trip
Transportation You pay $0 for You pay $0 for Prior authorization
(Non-Medicare- up to 24 one-way up to 24 one-way rules apply for routine
covered—routine) trips per year trips per year transportation services.
75-mile limit 75-mile limit You must use a SCAN-
applies to each applies to each contracted provider
one-way trip one-way trip to obtain routine
transportation services.
Medicare Part B Drugs You pay 20% of You pay 20% of Prior authorization rules
the total cost for the total cost for apply to select drugs.
chemotherapy and chemotherapy and
other Part B drugs other Part B drugs
*A benefit period begins the day you go into a hospital or SNF. The benefit period ends when you haven’t
received any inpatient hospital or SNF care for 60 days in a row.OUTPATIENT PRESCRIPTION DRUGS
You pay the following:
SCAN CLASSIC
Preferred Standard Preferred Standard Mail-Order
Retail Retail Retail Retail Pharmacy
Pharmacy Pharmacy Pharmacy Pharmacy 90-day
30-day supply 30-day supply 90-day supply 90-day supply supply
cost-sharing cost-sharing cost-sharing cost-sharing cost-sharing
Initial Coverage Stage
Tier 1 You pay $0 You pay $7 You pay $0 You pay $14 You pay $0
(Preferred Generic)
Tier 2 (Generic) You pay $5 You pay $15 You pay $10 You pay $30 You pay $0
Tier 3 You pay $42 You pay $47 You pay $106 You pay $121 You pay $106
(Preferred Brand)
Tier 4 You pay $95 You pay $100 You pay $265 You pay $280 You pay $265
(Non-Preferred Drug)
Tier 5 You pay 33% You pay 33% Not available Not available Not available
(Specialty Tier)
Coverage Gap Stage Begins after the total yearly drug cost (including what our plan has paid and
what you have paid) reaches $4,020.
You pay the same copays as in the Initial Coverage Stage for Tier 1 and Tier
2 drugs. For drugs in other tiers, you pay 25% of the negotiated price (and a
portion of the dispensing fee) for your brand name drugs and 25% of the cost
for your generic drugs.
Catastrophic Coverage After your yearly out-of-pocket drug costs reach $6,350, you pay the greater of:
Stage –– 5% of the cost, or
–– $3.60 copay for generic (including drugs that are treated like a generic)
and $8.95 copay for all other drugs.
Some of our network pharmacies have preferred cost-sharing. You may pay less for certain drugs
if you use these pharmacies. Cost-sharing may change depending on the pharmacy you choose
and when you enter another phase of the Part D benefit. For more information, please call our
Member Services Department at the number provided in this document or access your Evidence of
Coverage online.
You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an
in-network pharmacy.
Your cost-sharing may differ depending on the pharmacy you choose (e.g., Preferred Retail,
Standard Retail, Mail-Order, Long Term Care (LTC) or Home infusion, etc.) and whether you receive
a 30- or 90-day supply. For more information on the pharmacy-specific copays, please call SCAN
Member Services Department at the phone number in this document or access your Evidence of
Coverage online.SCAN PRIME
Preferred Standard Preferred Standard Mail-Order
Retail Retail Retail Retail Pharmacy
Pharmacy Pharmacy Pharmacy Pharmacy 90-day supply
30-day supply 30-day supply 90-day supply 90-day supply cost-sharing
cost-sharing cost-sharing cost-sharing cost-sharing
Initial Coverage Stage
Tier 1 You pay $0 You pay $5 You pay $0 You pay $10 You pay $0
(Preferred Generic)
Tier 2 (Generic) You pay $5 You pay $12 You pay $10 You pay $24 You pay $0
Tier 3 You pay $42 You pay $47 You pay $106 You pay $121 You pay $106
(Preferred Brand)
Tier 4 You pay $95 You pay $100 You pay $265 You pay $280 You pay $265
(Non-Preferred Drug)
Tier 5 You pay 33% You pay 33% Not available Not available Not available
(Specialty Tier)
Coverage Gap Stage Begins after the total yearly drug cost (including what our plan has paid and
what you have paid) reaches $4,020.
You pay the same copays as in the Initial Coverage Stage for Tier 1 and Tier
2 drugs. For drugs in other tiers, you pay 25% of the negotiated price (and a
portion of the dispensing fee) for your brand name drugs and 25% of the cost
for your generic drugs.
Catastrophic Coverage After your yearly out-of-pocket drug costs reach $6,350, you pay the greater of:
Stage –– 5% of the cost, or
–– $3.60 copay for generic (including drugs that are treated like a generic)
and $8.95 copay for all other drugs.
Some of our network pharmacies have preferred cost-sharing. You may pay less for certain drugs
if you use these pharmacies. Cost-sharing may change depending on the pharmacy you choose
and when you enter another phase of the Part D benefit. For more information, please call our
Member Services Department at the number provided in this document or access your Evidence of
Coverage online.
You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an
in-network pharmacy.
Your cost-sharing may differ depending on the pharmacy you choose (e.g., Preferred Retail,
Standard Retail, Mail-Order, Long Term Care (LTC) or Home infusion, etc.) and whether you receive
a 30- or 90-day supply. For more information on the pharmacy-specific copays, please call SCAN
Member Services Department at the phone number in this document or access your Evidence of
Coverage online.ADDITIONAL BENEFITS
Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.
BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW
Acupuncture Services You pay $15 You pay $0 for up You do not need a referral
copay for up to to 20 visits per for an initial acupuncture
30 visits per year combined visit. Any subsequent visits
year combined with routine require prior authorization.
with routine chiropractic
chiropractic and therapeutic
services massage services
Chiropractic Services
• Medicare-covered You pay $0 You pay $0 Prior authorization
chiropractic care rules apply
• Routine chiropractic You pay $15 You pay $0 for up You do not need a referral
care copay for up to to 20 visits per for an initial routine
30 visits per year combined chiropractor visit. Any
year combined with acupuncture subsequent visits require
with acupuncture and therapeutic prior authorization.
services massage services
Home Health Care You pay $0 You pay $0 Prior authorization rules
(Medicare-covered) apply
Medical Equipment/Supplies Prior authorization rules
• Durable Medical You pay 0% to 20% You pay 0% to 20% apply for covered durable
Equipment (e.g., of the total cost of the total cost medical equipment,
prosthetic devices, and
wheelchairs, oxygen)
certain diabetic supplies.
• Prosthetics (e.g., You pay 0% to 20% You pay 0% to 20%
braces, artificial limbs) of the total cost of the total cost
• Diabetic supplies You pay $0 You pay $0 SCAN covers diabetic
supplies such as glucose
monitors, test strips, and
control solution from
a select manufacturer.
Lancets are also covered
and are available from all
manufacturers.BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW
Telehealth Services You pay $0 You pay $0 A visit with a board-certified
doctor in the comfort of
your own home. This benefit
is for non-life threatening
conditions such as, but
not limited to, cough, flu,
nausea, sore throat, fever,
and allergies.
Visits with doctors can
be conducted either by
telephone or secure video
capabilities from your
computer or smart phone.OPTIONAL SUPPLEMENTAL BENEFITS Dental Services – SCAN CLASSIC ONLY Essential Dental Plan Monthly Premium $10 per month • Access to a large network of Delta Dental DHMO providers • Over 290 dental procedures included • Predictable copayments • Additional comprehensive dental coverage • Only available in the SCAN Classic Plan
SCAN Classic and SCAN Prime have a network of doctors, hospitals, pharmacies, and other providers.
If you use the providers that are not in our network, the plan may not pay for these services.
ABOUT SCAN CLASSIC AND SCAN PRIME
Who can join? You must:
- have both Medicare Part A and Part B
- live in the plan service area (Orange County, California)
- be a United States citizen or be lawfully present in the
United States
- not be medically determined to have end-stage renal
disease (ESRD)
Phone Number (Members) 1-800-559-3500
Phone Number (Non-Members) 1-877-870-4867
Calling this number will direct you to a
licensed insurance agent.
TTY 711
Hours of Operation October 1 to March 31:
8 a.m. to 8 p.m., 7 days a week
April 1 to September 30:
8 a.m. to 8 p.m., Monday through Friday
Messages received on holidays and outside of our business
hours will be returned within one business day.
Website http://www.scanhealthplan.com
To get more information about the coverage and costs of Original Medicare, look in your current
“Medicare & You” handbook. View it online at https://www.medicare.gov or get a copy by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
This information is not a complete description of benefits. Call 1-800-559-3500 (TTY: 711) for more
information.
You can get prescription drugs shipped to your home through our network mail-order delivery program,
which is called Express Scripts PharmacySM. 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’s Member Services at
1-800-559-3500, 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September
30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our
business hours will be returned within one business day). TTY: 711.Pre-Enrollment Checklist
Before making an enrollment decision, it is important that you fully understand our benefits and rules.
If you have any questions, you can call and speak to a customer service representative at 1-877-870-4867
(TTY users call 711) Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31. From
April 1 to September 30 hours are 8 a.m. to 8 p.m., Monday through Friday. Messages received on holidays
and outside of our business hours will be returned within one business day.
Understanding the Benefits
o Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services
that you routinely see a doctor. Visit www.scanhealthplan.com or call 1-877-870-4867 to view a
copy of the EOC.
o Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the
network. If they are not listed, it means you will likely have to select a new doctor.
o Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is
in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your
prescriptions.
Understanding Important Rules
o In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium.
This premium is normally taken out of your Social Security check each month.
o Benefits, premiums and/or copayments/co-insurance may change on January 1, 2021.
o Except in emergency or urgent situations, we do not cover services by out-of-network providers
(doctors who are not listed in the provider directory).
MASCAN Health Plan complies with applicable federal civil rights laws and does not discriminate,
exclude people, or treat them differently on the basis of, or because of, race, color, national origin,
age, disability, or sex.
SCAN Health Plan provides free aids and services to people with disabilities to communicate
effectively with us, such as qualified sign language interpreters, and written information in other
formats (large print, audio, accessible electronic formats, other formats).
SCAN Health Plan provides free language services to people whose primary language is not
English, such as qualified interpreters and information written in other languages.
If you need these services, contact SCAN Member Services.
If you believe that SCAN Health Plan has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a
grievance in person, by phone, mail, or fax, at:
SCAN Member Services
Attention: Grievance and Appeals Department
P.O. Box 22616, Long Beach, CA 90801-5616
1-800-559-3500 (TTY: 711)
FAX: 1-562-989-5181
Or by filling out the “File a Grievance” form on our website at:
https://www.scanhealthplan.com/contact-us/file-a-grievance
If you need help filing a grievance, SCAN Member Services is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 (TTY: 1-800-537-7697)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan
depends on contract renewal.English: ATTENTION: If you speak a language other than English, language assistance services,
free of charge, are available to you. Call 1-800-559-3500. (TTY: 711).
Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-800-559-3500. (TTY: 711).
Chinese Traditional: 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。(TTY: 711)。
Chinese Simplified: 注意：如果您使用中文，您可以免费获得语言援助服务，请致电 1-800-559-
3500。(TTY: 711)。
Vietnamese: CHÚ Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành
cho quý vị. Xin vui lòng gọi số 1-800-559-3500. (TTY: 711).
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng
tulong sa wika nang walang bayad. Tumawag sa 1-800-559-3500. (TTY: 711).
Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-559-3500 번으로 연락해 주십시오. (TTY: 711).
Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա Ձեզ անվճար կարող են
տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարե'ք 1-800-559-3500
հեռախոսահամարով: Հեռատիպի համարն է՝ 711:
Persian: تسهیال ت زبایی بوور ت راگگان، اگر به زبان فارسی گفتگو می کنید:توجه
.(TTY: 711) . تماس بگیرگد1-800-559-3500 با شماره.برای شما فراهم می باشد
Russian: ВНИМАНИЕ! Если вы говорите по-русски, вы можете бесплатно получить услуги
перевод;а. Звоните по телефону 1-800-559-3500 (TTY: 711).
Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。お問合せ
先1-800-559-3500. (TTY: 711).
Arabic: فإن خدمات المساعدة اللغوية تتوافر لك، إذا كنت تتحدث العربية:ملحوظة
.)711 : (الهاتف النصي.1-800-559-3500 اتصل برقم.بالمجان
Punjabi: ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰ ਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱ ਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।
1-800-559-3500 ਉੱਤੇ ਕਾਲ ਕਰੋ। (TTY: 711)।
Mon-Khmer, Cambodian: សូ មយកចិត្តទុកដាក់៖ ប ើសិនជាអ្ន កនិយាយភាសាខ្មែ រ បសវាជំនួយខ្ននកភាសា
បដាយមិនគិត្ថ្លៃ អាចមានសំរា ់ ំប រ ើអ្ន ក។ សូ មទូ រស័ព្ទបៅបេម 1-800-559-3500 ។ (TTY: 711) ។
Hmong: LUS CEEV: Yog tias koj hais lus Hmoob (Ntawv Suav - Hmoob), muaj kev pab txhais lus
pub dawb rau koj. Hu rau 1-800-559-3500. (TTY: 711).
Hindi: ध्यान दें : यदद आप द द
िं ी बोलते ैं तो आपके ललए मफ् ु त में भाषा स ायता सेवाएिं उपलब्ध ैं।
कॉल करें 1-800-559-3500, (TTY: 711)।
Thai: โปรดทราบ: ถ้ าคุณพูดภาษาไทย คุณสามารถใช้ บริการช่วยเหลือทางภาษาได้ ฟรี โทร 1-800-559-3500
(TTY: 711)
Lao: ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວ້ າພາສາ ລາວ, ການບໍລິການຊ່ ວຍເຫຼື ອດ້ ານພາສາ, ໂດຍບໍ່ເສັຽຄ່ າ, ແມ່ ນມີ
ພ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 1-800-559-3500 (TTY: 711).You can also read
