Benefit Highlights - SCAN Health Plan

2013 SCAN Health Plan ®
Benefit Highlights
Better Benefits.
Better Services.
Better Care.
SCAN Healthy at Home
(HMO SNP)
Los Angeles, Orange, Riverside
and San Bernardino Counties

Comprehensive Care
SCAN Healthy at Home
Monthly Plan Premium $0
Maximum Out-of-Pocket (MOOP) $6,700
PCP Office Visits $0
Specialist Office Visits $5
Immunizations $0
Lab Services and X-Rays $0
Breast Cancer Screening $0
Pap Smear/Pelvic Exam $0
Prostate Cancer Screening $0
Colorectal Cancer Screening $0
Annual Physical Exam $0
Diabetes Screening $0
Diabetic Supplies (lancets, test strips, monitor) $0
Hospital and Emergency Care
SCAN Healthy at Home
Inpatient Hospital Care $50 (Days 1-8)
Skilled Nursing Facility $0 (Days 1-20)
Outpatient Surgery $50 - $100
Outpatient Rehabilitation Services $10
Worldwide Emergency Care
$65 (Waived if admitted immediately)
Worldwide Urgent Care Services $35
Ambulance Services $100

Prescription Drug Coverage
SCAN Healthy at Home
Initial Coverage Stage – SCAN Contracted Pharmacy (1-month/31-Day Supply of Drugs)
Tier 1: Preferred Generic drugs $3
Tier 2: Non-Preferred Generic drugs $8
Tier 3: Preferred Brand drugs $39
Tier 4: Non-Preferred Brand drugs $80
Tier 5: Specialty drugs 33%
Tier 6: Select Care drugs $10
Use SCAN Mail Order Services and Pay a 2-Month Copay for a 3 Month (90 Day) Supply of Drugs.
(Not available for Tier 5 drugs)
We provide additional coverage for drugs in Tiers 1 and 2 in the Coverage Gap Stage. Please refer to your
Summary of Benefits for further information.
Additional Benefits and Services
SCAN Healthy at Home
Routine Eyewear Coverage
Routine Eye Exam
Routine Glasses or Contact Lenses
Routine Transportation
SCAN On Call ®
24-Hour Access to Medical Information
Optional Supplemental Dental
In-Home Meal Delivery
$175 coverage limit every 2 years for
frames/contacts
$0 (1 per year)
$25 every 2 years
$0 (30 one-way rides per year)
$0
Basic Option: $8 monthly Premium
High Option: $15 monthly Premium
$0 -- specific criteria/limitations apply
Personal Emergency Response System $15 per month -
installation is not included

3800 Kilroy Airport Way, Suite 100, Long Beach, CA 90806
For more information, contact your Authorized SCAN Representative or one of the numbers below:
Sales Information :
1-877-807-7226
8 a.m. – 8 p.m., 7 days per week
TTY Users : 711
Visit our web site
www.scanhealthplan.com
SCAN Healthy at Home is a Coordinated Care Plan
with a Medicare Advantage contract. This plan is
available to anyone with Medicare who has been
certified to require a Skilled Nursing Facility Level
of Care, and must also reside within the community.
Individuals must have both Medicare Part A, and
Medicare Part B to enroll. Eligible beneficiaries
must also have been diagnosed by their physician to
require a Skilled Nursing Facility Level of Care, and
must also reside within the community. You must
continue to pay your Medicare Part B premium. There
are no restrictions to the time of year when you may
enroll in SCAN Healthy at Home.
The benefit information provided herein is a brief
summary, not a comprehensive description of
benefits. SCAN Healthy at Home’s benefits, formulary,
provider/pharmacy network, premium, co-payments
and/or co-insurance may change on January 1, from
year to year.
SCAN Healthy at Home offers a network of Primary
Care Physicians, Specialists and Hospitals. You must
use plan providers, except in emergency or urgent
care situations or for out-of-area renal dialysis. If you
obtain routine care from out-of-network providers
neither Medicare nor SCAN Healthy at Home will be
responsible for the costs. Eligible beneficiaries must
use network pharmacies to access their prescription
drug benefit, except under non-routine circumstances.
For beneficiaries who qualify for “Extra Help”:
Premiums, Co-pays, Co-insurance and Deductibles
may vary based on the level of Extra Help that you
receive.
You may be able to get Extra Help to pay for your
prescription drug premiums and costs. To see if
you qualify for extra help, call: 1-800-MEDICARE
(1-800-633-4227). TTY users should call
1-877-486-2048, 24 hours a day/7 days a week;
The Social Security Office at 1-800-772-1213
between 7 a.m. and 7 p.m., Monday through Friday.
TTY users should call, 1-800-325-0778; or Your
State Medicaid Office.
Quantity limitations, copayments, exclusions and
restrictions may apply. Contact SCAN Healthy at
Home for more information
This information is available for free in other formats or
languages. Please contact our Customer Service number
at 1-800-559-3500 for additional information.
Esta información está disponible gratuitamente en
otros formatos o idiomas. Comuníquese a nuestro
número de Servicio al Cliente al 1-800-559-3500
para obtener más información.
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Y0057_SCAN_7415_2012. CMS Approved G7394 10/12