SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan

 
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SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan
Orange County

SCAN Classic (HMO)
SCAN Prime (HMO)
SCAN Balance (HMO SNP)

2020 Benefit Highlights
Medicare Advantage Plan
SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your 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)
SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan
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
SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan
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.
SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan
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.
SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan
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
SCAN Classic (HMO) SCAN Prime (HMO) - SCAN Balance (HMO SNP) 2020 Benefit Highlights - Find your Medicare Advantage plan
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-SMB400
SUMMARY 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
                                                   months
PREMIUM 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                 months
PREMIUM 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).

                                                                                                            MA
SCAN 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).
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