San Diego County Scripps Classic offered by SCAN Health Plan(HMO) Scripps Signature offered by SCAN Health Plan (HMO) Scripps Heart First offered by SCAN Health Plan (HMO SNP) 2015 Benefit Highlights San Diego County Benefit Highlights
San Diego County Benefit Highlights Comprehensive Care Scripps CLASSIC Scripps Signature Scripps Heart First Monthly Plan Premium $0 $68 $25 Primary Care Office Visits $15 $10 $15 Specialist Office Visits $35 $25 $35 Diabetic Self-Management Training $0 $0 $0 Diabetic Supplies (Lancets, Test Strips, Monitor) $0 $0 $0 Annual Physical Exam $0 $0 $0 Scripps Classic offered by SCAN Health Plan is a Medicare Advantage Plan including comprehensive preventive and hospital care plus complete prescription drug coverage. It s our most popular plan designed around the benefits and services that people use most. Scripps Signature offered by SCAN Health Plan is a Medicare Advantage Plan with low copayments for the preventive care and healthcare services you need. This plan is a good choice for those who see their doctor often or use a lot of services. Scripps Heart First offered by SCAN Health Plan is a Chronic Special Needs Plan available to anyone with Medicare who has been diagnosed with Cardiovascular Disorder or Chronic or Congestive Heart Failure. Preventive Services (Medicare-Covered Screenings) $0 $0 $0 Lab Services $0 $0 $0 Diagnostic Tests and Procedures $0 $0 $0 X-rays $0 $0 $0 Maximum Out of Pocket (MOOP) $3,200 $4,000 $3,400 Hospital and Emergency Care Inpatient Hospital Care $250 (Days 1-7) $0 (Days 8 and beyond) Skilled Nursing Facility $25 (Days 1-7) $40 (Days 8-20) $100 (Days 21-100) Scripps CLASSIC Scripps Signature Scripps Heart First $150 (Days 1-5) $0 (Days 6 and beyond) $0 (Days 1-20) $50 (Days 21-100) Outpatient Surgery $225 $75 $225 $250 (Days 1-7) $0 (Days 8 and beyond) $25 (Days 1-7) $40 (Days 8-20) $100 (Days 21-100) Emergency Care Urgent Care Services $45 (Worldwide) $25 (Worldwide) $45 (Worldwide) Ambulance Services $250 (per one-way trip) $100 (per one-way trip) $250 (per one-way trip)
Prescription Drug Coverage Initial Coverage Stage SCAN Contracted Pharmacy (1-month/31-Day Supply of Drugs) Scripps CLASSIC Tier 2: Non-Preferred Generic drugs $10 Tier 4: Non-Preferred Brand drugs $90 Tier 6: Select Care drugs $10 Scripps Signature Tier 2: Non-Preferred Generic drugs $8 Tier 4: Non-Preferred Brand drugs $85 Tier 6: Select Care drugs $10 Scripps Heart First Tier 2: Non-Preferred Generic drugs $10 Tier 4: Non-Preferred Brand drugs $95 Tier 6: Select Care drugs $0 Savings Opportunity Order a 3-month supply (90 days) of Tier 1, Tier 2 and Tier 6 drugs through SCAN Mail-Order Pharmacy and only pay for two months
Additional Benefits and Services Scripps CLASSIC SIGNATURE Heart First Vision Services (Routine) Eye Exam $0 (1 per year) $0 (1 per year) $0 (1 per year) Glasses or Contacts Copay $35 (every two $35 (every two $35 (every two Coverage for Frames or Contacts $80 (every two $105 (every two $105 (every two Hearing Services (Routine) Hearing Exam $0 (1 per year) $0 (1 per year) Coverage for Hearing Aids $500 (every two $500 (every two Transportation (Routine) $0 (12 one-way trips) $0 (12 one-way trips) $0 (10 one-way trips) Health Club Membership $0 $0 $0 Home Delivered Meals $0 (criteria and limitations apply) $0 (criteria and limitations apply) Acupuncture Services (Routine) $25 (10 visits per year combined with Chiropractic) Chiropractic Services (Routine) $25 (10 visits per year combined with Acupuncture) $10 (20 visits per year) Optional Supplemental Plans Scripps CLASSIC SIGNATURE Heart First Basic Dental Plan $8 per month $8 per month $8 per month Enhanced Dental Plan $16 per month $16 per month $16 per month
For more information, contact your Authorized SCAN Representative or call the number below: 3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806 Sales Information : 1-877-807-7226 8 a.m. 8 p.m., Monday through Friday, Pacific Time (8 a.m. 8 p.m., 7 days a week, Pacific Time, October 1 through February 14) TTY Users : 711 OR Visit our web site www.scanhealthplan.com 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 a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal. You must continue to pay your Medicare Part B premium. Heart First is available to anyone with Medicare who has been diagnosed with Chronic or Congestive Heart Failure, Cardiac Arrhythmia, Coronary Artery Disease, Peripheral Vascular Disease, or Chronic Venous Thromboembolic Disorder. SCAN Balance is available to anyone with Medicare who has been diagnosed with Diabetes Mellitus. The benefit information provided herein is a brief summary, not a complete description of benefits. Benefits, formulary, provider/pharmacy network, premium, co-payments and/or co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. For more information contact the plan. Calling the agent number will direct you to a licensed insurance agent. Other Providers are available in our network. You can get prescription drugs shipped to your home through our network mail-order delivery program. Typically, you should expect to receive your prescription drugs within 14 days from the time the mail-order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call the SCAN Personal Assistance Line PAL at 1-866-722-6725), 8 a.m. 8 p.m., 7 days a week. TTY users should call 711. This information is available for free in other languages. Please call our customer service number at 1-800-559-3500, 8 a.m. 8 p.m., seven days a week. TTY users call 711. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro número de servicio al cliente 1-800-559-3500, 8 a.m. 8 p.m., siete días a la semana. Los usuarios de TTY deben llamar al 711. Y0057_SCAN_8798_2014F File & Use Accepted 08272014 G8733 08/14 15C-BHL701