Summary of Benefits - SCAN Health Plan
Summary of Benefits - SCAN Health Plan
Summary of Benefits - SCAN Health Plan
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Benefit Original Medicare <strong>SCAN</strong> CLASSIC (HMO) <strong>SCAN</strong> OPTIONS (HMO)<br />
Optional Supplemental Package #1 (cont.)<br />
Dental Services<br />
In-Network<br />
- $5 copay for up to 2 cleaning(s)<br />
every year<br />
- $0 copay for up to 2 oral exam(s)<br />
every year<br />
- $0 copay for up to 1 dental<br />
x-ray(s) every six months<br />
In-Network<br />
- $5 copay for up to 2 cleaning(s)<br />
every year<br />
- $0 copay for up to 2 oral exam(s)<br />
every year<br />
- $0 copay for up to 1 dental<br />
x-ray(s) every six months<br />
Optional Supplemental Package #2<br />
32<br />
Premium and Other<br />
Important Information<br />
General<br />
Package: 2 - High Option:<br />
$15 monthly premium, in<br />
addition to your $49 monthly<br />
plan premium and the monthly<br />
Medicare Part B premium, for the<br />
following optional benefits:<br />
- Preventive Dental<br />
General<br />
Package: 2 - High Option:<br />
$15 monthly premium, in addition<br />
to your $35 monthly plan premium<br />
and the monthly Medicare Part B<br />
premium, for the following optional<br />
benefits:<br />
- Preventive Dental<br />
Dental Services<br />
In-Network<br />
- $5 copay for up to 2 cleaning(s)<br />
every year<br />
- $0 copay for up to 2 oral exam(s)<br />
every year<br />
- $0 copay for up to 1 dental<br />
x-ray(s) every six months<br />
In-Network<br />
- $5 copay for up to 2 cleaning(s)<br />
every year<br />
- $0 copay for up to 2 oral exam(s)<br />
every year<br />
- $0 copay for up to 1 dental<br />
x-ray(s) every six months
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