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San Bernardino CountySCAN Classic (HMO)SCAN Prime (HMO)SCAN Heart First (HMO SNP)2021 Benefit HighlightsMedicare Advantage Plan
Plan DetailsSCAN ClassicSCAN PrimeSCAN Heart FirstMonthly Plan Premium 0 23 0Annual Part D Plan Deductible 0 0 0Comprehensive CareSCAN ClassicSCAN PrimeSCAN Heart FirstPrimary Care Office Visits 0 0 0Specialist Office Visits 0 0 0Diabetic Self-ManagementTraining 0 0 0Diabetic Supplies(lancets, test strips, monitor) 0 0 0Annual Physical Exam 0 0 0Preventive Services(Medicare-covered screenings) 0 0 0Lab Services and X-rays 0 0 0Diagnostic Tests and Procedures 0 0 0Outpatient Rehabilitation(e.g. PT, OT, ST) 0 0 0Diagnostic Radiology(e.g. MRI, CT, ultrasound) 50 50 50 0-20% 0-20% 0-20%Hospital and EmergencyCareSCAN ClassicSCAN PrimeSCAN Heart FirstInpatient Hospital Care 0 per dayunlimited days 0 per dayunlimited days 0 per dayunlimited daysSkilled Nursing Facility 0 per day(days 1–20) 100 per day(days 21–100) 0 per day(days 1–20) 100 per day(days 21–100) 0 per day(days 1–20) 100 per day(days 21–100) 0- 100 0- 100 0- 100Emergency Care 90 (worldwide) 0 (if admittedimmediately) 90 (worldwide) 0 (if admittedimmediately) 90 (worldwide) 0 (if admittedimmediately)Urgent Care Services 0 (worldwide) 0 (worldwide) 0 (worldwide)Ambulance Services 200 200 200SCAN ClassicSCAN PrimeSCAN Heart First 999 699 999Durable Medical EquipmentOutpatient SurgeryMaximum Out-of-PocketAnnual Maximum Out-of-Pocket(MOOP)
Prescription DrugCoveragePHARMACY NETWORKPart D DeductibleSCAN ClassicSCAN PrimeSCAN Heart ANDARD 0 0 0 0 0 0Initial Coverage Stage - SCAN Contracted Retail Pharmacy (1-month/30-day supply)TIER 1: Preferred Generic 0 9 0 7 0 7TIER 2: Generic 7 15 7 14 7 14Insulin 25 35 25 35 25 35Other Drugs 37 47 37 47 37 47TIER 4: Non-Preferred Drug 95 100 95 100 95 100TIER 5: Specialty Tier33%33%33%33%33%33%Tiers1 and 2Tiers1 and 2Tiers1 and 2Tiers1 and 2Tiers1 and 2Tiers1 and 2Tier 3(insulinonly)Tier 3(insulinonly)Tier 3(insulinonly)Tier 3(insulinonly)Tier 3(insulinonly)Tier 3(insulinonly)TIER 3:PreferredBrandCoverage GapMore Ways to Save on PrescriptionsPay 0 for a 3-month supply for Tiers 1 and 2 through Express Scripts Mail Order pharmacy ORpay for 2 months when you get a 3-month supply for Tiers 1 and 2 at your local retail pharmacy.Optional DentalMonthly Plan PremiumEssential Dental PlanSCAN ClassicSCAN PrimeSCAN Heart First 10Not Available 10
Included extras you get with SCANCore ExtrasVision Services (routine)Eye examGlasses or contact lensesCoverage for frames orcontactsSCAN ClassicSCAN PrimeSCAN Heart First 10 (1 every 12 months) 10 (every 24 months) 135 (every 24 months) 0 (1 every 12 months) 30 (every 24 months) 175 (every 24 months) 0 (1 every 12 months) 30 (every 24 months) 175 (every 24 months)Dental Services (routine)Dental examsCleaningDeep cleaning 0 (2 visits per year) 0 (2 visits per year) 0 (per quadrant) 10 (2 visits per year) 5 (2 visits per year) 0 (per quadrant) 0 (2 visits per year) 0 (2 visits per year) 0 (per quadrant)Transportation (routine)*Non-medical** 0 (24 one-way trips/year)Not Available 0 (24 one-way trips/year)Not Available 0 (24 one-way trips/year)12 of the 24 tripsRoutine Acupuncture,Chiropractic, andTherapeutic MassageServices 15 per visit (30 visits/yearcombined – Acupunctureand Chiropractic only) 0 per visit (20 visits/year 15 per visit (30 visits/yearcombined – Acupuncturecombined – Acupunctureand Chiropractic)and Chiropractic only) 5 per visit (20 visits peryear – Therapeutic Massage)Podiatry Services (routine) 0 (6 visits per year) 0 (6 visits per year) 0 (6 visits per year)Hearing Services (routine)Hearing aid copay orHearing aid allowance 450/ 750 per aid/year 200/ 400 per aid/year or 3,000 for up to 2 hearingaids 450/ 750 per aid/yearFeatured ExtrasSCAN ClassicSCAN PrimeSCAN Heart FirstTelehealth 0 per visit(per phone or video visit) 0 per visit(per phone or video visit) 0 per visit(per phone or video visit)Generic Viagra(Sildenafil tabs 25mg,50mg, 100mg)Tier 1 copay – maximum 4tablets per monthTier 1 copay – maximum 4tablets per monthNot AvailableSCAN HEALTHtechTechnology supportassistance 0 per call/unlimited calls 0 per call/unlimited calls 0 per call/unlimited callsSCAN on the goAccess to many of yourbenefits wherever you goAccess to many of yourbenefits wherever you goAccess to many of yourbenefits wherever you goSCAN Travel AssuranceUnlimited urgent/emergentworldwide coverageUnlimited urgent/emergentworldwide coverageUnlimited urgent/emergentworldwide coverageSolutions forHealthy LivingSCAN ClassicSCAN PrimeSCAN Heart FirstHealth Club Membership 0 (SilverSneakers ) 0 (SilverSneakers ) 0 (SilverSneakers )Over-the-Counter (OTC) 30 allowance per quarterwith rollover 50 allowance per quarterwith rollover 30 allowance per quarterwith rolloverFitbitTM Fitness Tracker 0 for the Fitbit ProximaHR (1 Fitbit every 2 years) 0 for the Fitbit Charge 4(1 Fitbit every 2 years) 0 for the Fitbit ProximaHR (1 Fitbit every 2 years)BrainHQ 0 online games to keep 0 online games to keep 0 online games to keepyour brain healthy and active your brain healthy and active your brain healthy and active*75-mile limit will apply to each one-way trip. **Trips to: health club, grocery store, or senior center.
The SCAN StorySCAN, a not-for-profit health plan, was founded in 1977 by seniors, for seniors. More thanforty years later, seniors are still at the heart of all we do. You can count on SCAN to keepyou healthy and independent for years to come. That’s been our mission since day one.Solutions for IndependenceIn addition to the core benefits and extra services described inside,SCAN knows that sometimes our members need a little more care tostay independent in their own homes for as long as possible, so we’veincluded these special benefits in your plan to help you do just that.SCAN Respite Care Services*Providing a short-term break from the demands ofcaregiving, SCAN offers respite care for full-time, unpaidcaregivers caring for SCAN members. SCAN Classic(HMO)SCAN Classic is our mostcompetitive plan offering all thebenefits of Original Medicareand more.Includes:Up to 40 hours per year (4-hour minimum per visit) in themember’s home where the primary care giving takes place.SCAN Returning to Home*SCAN PrimeExtra help at home after a hospital stay can mean all thedifference in your recovery. SCAN is there for you with:(HMO) 0 personal in-home care visits (bathing/dressing, etc.)up to 40 hours per year – 4-hour minimum per visit 0 home-delivered meals up to 28 days per year 0 telephonic personal support servicesSCAN Home AdvantageSCAN Prime includes all ofthe benefits of SCAN Classic— plus enhanced dentaland over-the counter drugcoverage, and the widest arrayof extra benefits.Includes:As you age you want the confidence that your home cansafely support your changing needs. SCAN provides youwith a: 0 cost in-home safety evaluation 0 cost follow-up visitChronic Condition Meals*Maintaining proper nutrition can help manage chronichealth conditions. SCAN delivers on its promise tokeeping seniors healthy with 0 home-delivered meals, forup to 28 days per year.Emergency Response System*Personal emergency response system that enablesmembers to remain at home, living safely andindependently. 0 (includes installation and monthly fees)*Criteria and limitations apply.SCAN Heart First(HMO SNP)SCAN Heart First is a SpecialNeeds Plan designed to helpmembers who have are livingwith Cardiovascular Disorderor Chronic or CongestiveHeart Failure.Includes:
Contact an authorized SCANrepresentative today877-870-4867Or visit:www.scanhealthplan.comTTY users: 711October 1 to March 31: 8 a.m. to 8 p.m.,7 days a weekApril 1 to September 30: 8 a.m. to 8 p.m.,Monday through FridaySCAN Classic (HMO), SCAN Prime (HMO) and SCAN Heart First (HMO SNP) are HMO plans with Medicarecontracts. Enrollment in SCAN Health Plan depends on contract renewal. You must continue to pay your MedicarePart B premium.Copay/coinsurance may vary by plan and county or depending on the pharmacy you choose (e.g., Preferredor Standard, etc.) or whether you receive a one-month or a three-month supply or when you enter anotherphase of the Part D benefit or if you receive “Extra Help.” You can fill your prescriptions at any of our networkpharmacies, but you may pay less at a Preferred pharmacy. Check your Evidence of Coverage or call SCANMember Services for details.You can get prescription drugs shipped to your home through our network mail-order delivery program. ExpressScripts Pharmacy is our Preferred mail order pharmacy. While you can fill your prescription medications at any ofour network mail order pharmacies, you may pay less at the Preferred mail order pharmacy. Typically, you shouldexpect to receive your prescription drugs within 14 days from the time that Express Scripts mail-order pharmacyreceives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN HealthPlan’s Member Services. For your mail order prescriptions, you have the option to sign up for an automatic refillprogram by contacting Express Scripts Pharmacy at 1-866-553-4125, 24 hours a day, 7 days a week. TTY userscall 711. You may opt out of automatic deliveries at any time.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 deasistencia lingüística. Llame al 1-800-559-3500. (TTY: 711). �得語言援助服務。請致電 1-800-559-3500。（聽障專線：711）。Y0057 SCAN 12070 2020F M 09192020 R1447 8/20 21C-BHL501
SCAN Returning to Home* Extra help at home after a hospital stay can mean all the difference in your recovery. SCAN is there for you with: 0 personal in-home care visits (bathing/dressing, etc.) up to 40 hours per year – 4-hour minimum per visit 0 home-delivered meals up to 2
