2019 Benefit Highlights
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1 San Diego County 2019 Benefit Highlights Scripps Plus offered by SCAN Health Plan (HMO) Medicare Advantage Plan
2 Plan Details With Medicare & Full Monthly Plan Premium $0 $34.80 With Medicare Only Annual Plan Deductible $0 Medicare fee-for-service deductible Comprehensive Care Medicare & Full Medicare Only Primary Care Office Visits $0 $0 Specialist Office Visits $0 $0 Diabetic Self-Management Training $0 $0 Diabetic Supplies (lancets, test strips, monitor) $0 $0 Annual Physical Exam $0 $0 Preventive Services (Medicare-covered screenings) $0 $0 Lab Services and X-rays $0 0% 20% Diagnostic Tests and Procedures $0 20% Outpatient Rehabilitation (e.g. PT, OT, ST) $0 20% Durable Medical Equipment $0 20% Diagnostic Radiology (e.g. MRI, CT) $0 20% Hospital and Emergency Care Medicare & Full Medicare Only Inpatient Hospital Care $0 Medicare fee-for-service costs Skilled Nursing Facility $0 Medicare fee-for-service costs Outpatient Surgery $0 20% Emergency Care $0 (worldwide) 20% (worldwide) Urgent Care Services $0 (worldwide) 20% (worldwide) Ambulance Services $0 20% Maximum Out-of-Pocket Medicare & Full Medicare Only Annual Maximum Out-of-Pocket (MOOP) $6,700 $6,700
3 Prescription Drug Coverage With Medicare & Full With Medicare Only Pharmacy Network Preferred Standard Preferred Standard Part D Deductible $0 $0 $415 $415 Initial Coverage Stage - SCAN Contracted Retail Pharmacy (1-month/30-day supply) TIER 1: Preferred Generic $0 $0 or $1.25 or $3.40 $0 $19 TIER 2: Generic TIER 3: Preferred Brand TIER 4: Non-Preferred Drug TIER 5: Specialty Tier Generic drugs (including drugs treated like a generic): $0 or $1.25 or $3.40 All other drugs: $0 or $3.80 or $ % of the total drug cost Your copay/coinsurance may change when you enter another phase of the Part D benefit. If you qualify for Extra Help with your prescription drug costs, the Extra Help program will pay all or part of your monthly plan premium and your prescription drug deductibles and copay/coinsurance. What Are Additional Benefits and Services? Additional Benefits are benefits and services not offered by Original Medicare. These services do not need a referral from your doctor.
4 Additional Benefits and Services Vision Services (routine) Eye exam Coverage for frames and lens options or contact lenses Transportation (routine) $0 (1 per year) $300 (every 2 years) $0 (up to 32 one-way trips per year)* Health Club Membership $0 Acupuncture and Chiropractic Services (routine) $5 per visit (unlimited) Podiatry Services (routine) Personal Emergency Response System (PERS) $0 (6 visits per year) $15 per month (one-time installation fee of $25 applies) Dental Services (routine) Dental exams $0 Dental cleanings Dental X-rays $0 (2 every 12 months) $0 (1 every 6 months) Hearing Services (routine) Hearing exam Hearing aid copay Over-the-Counter (OTC) Telehealth Returning to Home (criteria & limitations apply) Home Advantage $0 (1 per year) $699/$999 (per aid/per year) $50 quarterly allowance (for items ordered through SCAN s OTC mail-order catalog) $40 virtual office visit (telephonic or video) $0 personal in-home care visits (bathing, dressing, etc.) $0 home delivered meals $0 telephonic personal support services $0 in-home safety evaluation $0 follow-up visit * 75-mile limit will apply to each one-way trip
5 The SCAN Story SCAN, a not-for-profit health plan, was founded in 1977 by seniors, for seniors. More than forty years later, seniors are still at the heart of all we do. You can count on SCAN to keep you healthy and independent for years to come. That s been our mission since day one. Scripps Plus offered by SCAN Health Plan (HMO) Scripps Plus offered by SCAN Health Plan (HMO) includes comprehensive medical, hospital and pharmacy coverage. SCAN Plus also offers many benefits above and beyond Original Medicare such as dental, transportation, gym membership, vision, hearing coverage, over the counter prescription drug coverage and more. Together with our partner Scripps Health, you get the comprehensive services and care from one of the nation s top health systems.
6 Contact an authorized SCAN representative today Or visit: TTY users: a.m. to 8 p.m., Monday through Friday, Pacific Time 8 a.m. to 8 p.m., 7 days a week, Pacific Time (From October 1 through March 31) Scripps Plus offered by SCAN Health Plan (HMO) is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal. You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Call (TTY: 711) for more information. Calling the agent number will direct you to a licensed insurance agent. You can get prescription drugs shipped to your home through our network mail-order delivery program which is called Express Scripts Home Delivery. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail-order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN Health Plan Member Services. SCAN Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 ( 聽障專線 :711) Y0057_SCAN_10870_2018F_M_ R557 08/18 19C-BHL225
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