Summary of Benefits - SCAN Health Plan

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Benefit Original Medicare SCAN CLASSIC (HMO) SCAN OPTIONS (HMO) Outpatient Medical Services and Supplies 26. Dental Services Preventive dental services (such as cleaning) not covered. General Authorization rules may apply. General Authorization rules may apply. In-Network In general, preventive dental benefits (such as cleaning) not covered. In-Network In general, preventive dental benefits (such as cleaning) not covered. $15 copay for Medicare-covered dental benefits $10 copay for Medicare-covered dental benefits 29 27. Hearing Services Supplemental routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. General Authorization rules may apply. In-Network In general, supplemental routine hearing exams and hearing aids not covered. General Authorization rules may apply. In-Network In general, supplemental routine hearing exams and hearing aids not covered. $10 copay for Medicare-covered diagnostic hearing exams $10 copay for Medicare-covered diagnostic hearing exams
Benefit Original Medicare SCAN CLASSIC (HMO) SCAN OPTIONS (HMO) 30 Outpatient Medical Services and Supplies (cont.) 28. Vision Services 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. Supplemental routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Annual glaucoma screenings covered for people at risk. General Authorization rules may apply. In-Network $10 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery. $0 to $10 copay for Medicarecovered exams to diagnose and treat diseases and conditions of the eye. $0 copay for up to 1 supplemental routine eye exam(s) every year $35 copay for up to 1 pair(s) of glasses every two years $35 copay for up to 1 pair(s) of contacts every two years $35 copay for up to 1 pair(s) of lenses every two years $35 copay for up to 1 frame(s) every two years $105 plan coverage limit for contact lenses every two years. $105 plan coverage limit for eye glass frames every two years. General Authorization rules may apply. In-Network $10 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery. $0 to $10 copay for Medicarecovered exams to diagnose and treat diseases and conditions of the eye. $0 copay for up to 1 supplemental routine eye exam(s) every year $35 copay for up to 1 pair(s) of glasses every two years $35 copay for up to 1 pair(s) of contacts every two years $35 copay for up to 1 pair(s) of lenses every two years $35 copay for up to 1 frame(s) every two years $105 plan coverage limit for contact lenses every two years. $105 plan coverage limit for eye glass frames every two years
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Summary of Benefits - SCAN Health Plan

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