Summary of Benefits - SCAN Health Plan

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Benefit Original Medicare SCAN CLASSIC (HMO) SCAN OPTIONS (HMO) 21 Prescription Drug Benefits (cont.) 25. Outpatient Prescription Drugs (cont.) Tier 6: Select Care Drugs - $10 copay for a one-month (31- day) supply of drugs in this tier - $30 copay for a three-month (90- day) supply of drugs in this tier Long Term Care Pharmacy Tier 1: Preferred Generic - $5 copay for a one-month (31- day) supply of generic drugs in this tier Tier 2: Non-Preferred Generic - $10 copay for a one-month (31- day) supply of generic drugs in this tier Tier 3: Preferred Brand - $40 copay for a one-month (31-day) supply of brand drugs covered in this tier Tier 4: Non-Preferred Brand - $65 copay for a one-month (31-day) supply of brand drugs covered in this tier Tier 5: Specialty Tier - 33% coinsurance for a onemonth (31-day) supply of drugs in this tier Tier 6: Select Care Drugs - $10 copay for a one-month (31- day) supply of drugs in this tier - $30 copay for a three-month (90-day) supply of drugs in this tier Long Term Care Pharmacy Tier 1: Preferred Generic - $5 copay for a one-month (31- day) supply of generic drugs in this tier Tier 2: Non-Preferred Generic - $10 copay for a one-month (31- day) supply of generic drugs in this tier Tier 3: Preferred Brand - $45 copay for a one-month (31-day) supply of brand drugs covered in this tier Tier 4: Non-Preferred Brand - $75 copay for a one-month (31-day) supply of brand drugs covered in this tier Tier 5: Specialty Tier - 33% coinsurance for a one-month (31-day) supply of drugs in this tier
Benefit Original Medicare SCAN CLASSIC (HMO) SCAN OPTIONS (HMO) 22 Prescription Drug Benefits (cont.) 25. Outpatient Prescription Drugs (cont.) Tier 6: Select Care Drugs - $10 copay for a one-month (31-day) supply of brand drugs covered in this tier Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/ collection when less than a onemonth supply is dispensed. Mail Order Tier 1: Preferred Generic - $10 copay for a three-month (90- day) supply of drugs in this tier Tier 2: Non-Preferred Generic - $20 copay for a three-month (90- day) supply of drugs in this tier Tier 3: Preferred Brand - $80 copay for a three-month (90- day) supply of drugs in this tier Tier 4: Non-Preferred Brand - $130 copay for a three-month (90-day) supply of drugs in this tier Tier 6: Select Care Drugs - $20 copay for a three-month (90- day) supply of drugs in this tier Tier 6: Select Care Drugs - $10 copay for a one-month (31-day) supply of brand drugs covered in this tier Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. Mail Order Tier 1: Preferred Generic - $10 copay for a three-month (90- day) supply of drugs in this tier Tier 2: Non-Preferred Generic - $20 copay for a three-month (90- day) supply of drugs in this tier Tier 3: Preferred Brand - $90 copay for a three-month (90- day) supply of drugs in this tier Tier 4: Non-Preferred Brand - $150 copay for a three-month (90-day) supply of drugs in this tier Tier 6: Select Care Drugs - $20 copay for a three-month (90- day) supply of drugs in this tier
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Summary of Benefits - SCAN Health Plan

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