2019 Benefit Highlights
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1 San Diego County 2019 Benefit Highlights Scripps Classic (HMO), Scripps Heart First (HMO SNP) and Scripps Signature (HMO) Medicare Advantage Plans
2 Plan Details Monthly Plan Premium $0 $26 $74 Annual Plan Deductible $0 $0 $0 Comprehensive Care Primary Care Office Visits $10 $15 $10 Specialist Office Visits $35 $35 $25 Diabetic Self-Management Training $0 $0 $0 Diabetic Supplies (lancets, test strips, monitor) $0 $0 $0 Annual Physical Exam $0 $0 $0 Preventive Services (Medicare-covered screenings) $0 $0 $0 Lab Services and X-rays $0 $0 $0 Diagnostic Tests and Procedures $0 $0 $0 Outpatient Rehabilitation (e.g. PT, OT, ST) Diagnostic Radiology (e.g. MRI, CT) $40 $40 $25 $50 $50 $50 Durable Medical Equipment 20% 20% 20% Hospital and Emergency Care Inpatient Hospital Care Skilled Nursing Facility Maximum Out-of-Pocket $295 per day (days 1 7) $0 per day (days 8+) $0 per day (days 1 20) $140 per day (days ) $295 per day (days 1 7) $0 per day (days 8+) $0 per day (days 1 20) $120 per day (days ) Outpatient Surgery $250 $300 $250 $300 $75 Emergency Care $90 (worldwide) $0 (if admitted immediately) $90 (worldwide) $0 (if admitted immediately) $150 per day (days 1 5) Annual Maximum Out-of-Pocket (MOOP) $3,400 $3,400 $4,000 $0 per day (days 6+) $0 per day (days 1 20) $50 per day (days ) $90 (worldwide) $0 (if admitted immediately) Urgent Care Services $30 (worldwide) $30 (worldwide) $25 (worldwide) Ambulance Services $250 $250 $100
3 Prescription Drug 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 $7 $0 $7 TIER 2: Generic $5 $12 $5 $12 $3 $10 TIER 3: Preferred Brand $42 $47 $42 $47 $42 $47 TIER 4: Non-Preferred Drug $95 $100 $95 $100 $95 $100 TIER 5: Specialty Tier 33% 33% 33% 33% 33% 33% Coverage Gap N/A N/A Tier 1 Tier 1 Tiers 1 and 2 Tiers 1 and 2 Savings Opportunities For greatest savings, get a 3-month (90-day) supply of Tier 1 and Tier 2 drugs at Express Scripts Mail-Order for $0. Or fill a 3-month (90-day) supply of Tier 1 and Tier 2 drugs at your local retail pharmacy and pay for only 2 months. Optional Supplemental Plans Basic Dental Plan $6 $6 $6 Enhanced Dental Plan $16 $16 $16 What Are Additional Benefits and Services? Additional Benefits are benefits and services not offered by Original Medicare. These services do not need a referral from your doctor.
4 Additional Benefits and Services Vision Services (routine) Eye exam $0 (1 per year) $0 (1 per year) $0 (1 per year) Glasses or contact lenses $0 (every 2 years) $0 (every 2 years) $30 (every 2 years) Coverage for frames/contacts $130 (every 2 years) $130 (every 2 years) $175 (every 2 years) Transportation (routine) $0 (up to 24 one-way trips per year)* $0 (up to 18 one-way trips per year)* $0 (up to 16 one-way trips per year)* Health Club Membership $0 $0 $0 Acupuncture and Chiropractic Services (routine) $10 per visit (12 visits per year combined) $9 per visit (30 visits per year combined) $10 per visit (30 visits per year combined) Podiatry Services (routine) $0 (6 visits per year) $0 (6 visits per year) $0 (6 visits per year) Home Delivered Meals $0 (criteria & limitations apply) See Returning to Home See Returning to Home Hearing Services (routine) Hearing exam $0 (1 per year) $0 (1 per year) $0 (1 per year) Hearing aid copay $699/$999 (per aid/per year) $699/$999 (per aid/per year) $699/$999 (per aid/per year) Telehealth $40 virtual office visit (telephonic or video) $40 virtual office visit (telephonic or video) $40 virtual office visit (telephonic or video) Returning to Home (criteria & limitations apply) N/A $0 personal in-home care visits (bathing, dressing, etc.) $0 home delivered meals $0 personal in-home care visits (bathing, dressing, etc.) $0 home delivered meals $0 telephonic personal support services $0 telephonic personal support services Home Advantage N/A $0 in-home safety evaluation N/A $0 follow-up visit * 75-mile limit will apply to each one-way trip
5 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. Scripps Classic offered by SCAN Health Plan (HMO) A Medicare Advantage Prescription Drug Plan (MAPD) offering all the benefits of Medicare and more. Scripps Classic offered by SCAN Health Plan (HMO) is our most competitive and popular plan. It includes comprehensive medical, hospital and pharmacy coverage. In addition, Scripps Classic offers the widest array of benefits not covered by Original Medicare, such as a gym membership, vision, hearing aids and more. Together with our partner Scripps Health, you get the comprehensive services and care from one of the nation s top health systems. Scripps Signature offered by SCAN Health Plan (HMO) A Medicare Advantage Prescription Drug Plan (MAPD) with low copayments for the services you use most. Scripps Signature offered by SCAN Health Plan (HMO) includes comprehensive preventive and hospital care for a lower copay plus complete prescription drug coverage, as well as benefits not covered by Original Medicare such as a gym membership, vision, hearing and more. Together with our partner Scripps Health, you get the comprehensive services and care from one of the nation s top health systems. Scripps Heart First offered by SCAN Health Plan (HMO SNP) Available to anyone with Medicare who has been diagnosed with Cardiovascular Disorder or Chronic or Congestive Heart Failure. Scripps Heart First offered by SCAN Health Plan (HMO SNP) includes comprehensive medical, hospital and pharmacy coverage, in addition to a wide array of benefits not covered by Original Medicare, such as a gym membership, vision, hearing aids and more. Together with our partner Scripps Health, you get the comprehensive services and care from one of the nation s top health systems.
6 Contact an authorized SCAN representative today Or visit: TTY users: a.m. to 8 p.m., Monday through Friday, Pacific Time 8 a.m. to 8 p.m., 7 days a week, Pacific Time (From October 1 through March 31) Scripps Classic offered by SCAN Health Plan (HMO), Scripps Signature offered by SCAN Health Plan (HMO) and Scripps Heart First offered by SCAN Health Plan (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 (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 Home Delivery. 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 Member Services. SCAN Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (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 ( 聽障專線 :711) Y0057_SCAN_10870_2018F_M_ R552 08/18 19C-BHL701
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