2018 Benefit Highlights
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1 Marin County 2018 Benefit Highlights SCAN Classic (HMO), SCAN Balance (HMO SNP), and Heart First (HMO SNP) Medicare Advantage Plans
2 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. Additional Benefits and Services Vision Services (Routine) Eye Exam $0 (1 per year) $0 (1 per year) $0 (1 per year) Glasses or Contact Lenses $0 $0 $0 Coverage for Frames or Contacts Hearing Services (Routine) Hearing Exam $0 (1 per year) $0 (1 per year) $0 (1 per year) Hearing Aid Copay Acupuncture and Chiropractic Services (Routine) (30 visits per year (12 visits per year (12 visits per year Transportation (Routine) $0 (up to 12 one-way trips per year)* $0 (up to 12 oneway trips per year)* Health Club Membership $0 $0 $0 Podiatry Services (Routine) $0 (6 visits per year) $10 (12 visits per year) $10 (12 visits per year) Personal Emergency Response System $15 per month (one-time installation fee of $25 applies) $15 per month (one-time installation fee of $25 applies) Home-Delivered Meals $0 (criteria & limitations apply) $0 (criteria & limitations apply) Optional Supplemental Plans Basic Dental Plan $6 $6 $6 Enhanced Dental Plan $16 $16 $16 * 75-mile limit will apply to each one-way trip
3 Marin County Plan Details Monthly Plan Premium $80 $65 $65 Annual Plan Deductible $0 $0 $0 Comprehensive Care Primary Care Office Visits $5 $0 $0 Specialist Office Visits $10 $0 $0 Diabetic Self-Management Training $0 $0 $0 Diabetic Supplies (Lancets, Test Strips, Monitor) $0 $0 $0 Annual Physical Exam $0 $0 $0 Preventive Services (Medicare-Covered Screenings) $0 $0 $0 Lab Services and X-rays $0 $0 $0 Diagnostic Tests and Procedures $0 $0 $0 SCAN Classic A Medicare Advantage Plan which includes 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. SCAN Balance A Chronic Special Needs Plan available to anyone with Medicare who has been diagnosed with diabetes mellitus. Outpatient Rehabilitation (e.g., PT, OT, ST) $15 $20 $20 Diagnostic Radiology (e.g., MRI, CT) 20% 20% 20% Durable Medical Equipment 20% 20% 20% Hospital and Emergency Care Inpatient Hospital Care Skilled Nursing Facility $0 per day (days 1 10) $20 per day (days 11 20) $0 per day (days 1 20) Outpatient Surgery $75 $75 $100 $75 $100 $0 per day (days 1 20) Emergency Care $80 (worldwide) $80 (U.S. only) $80 (U.S. only) Heart First A Chronic Special Needs Plan available to anyone with Medicare who has been diagnosed with certain cardiovascular disorders and diseases, or chronic or congestive heart failure. Urgent Care Services $35 (worldwide) $35 (U.S. only) $35 (U.S. only) Ambulance Services $200 (per one-way trip) $95 (per one-way trip) $95 (per one-way trip) Maximum Out-of-Pocket Annual Maximum Out-of-Pocket (MOOP) $3,400 $5,000 $5,000
4 Prescription Drug Coverage Pharmacy Network Preferred Standard Preferred Standard Preferred Standard Part D Deductible $0 $0 $0 $0 $0 $0 Initial Coverage Stage SCAN-Contracted Pharmacy (1-month/30-day Supply of Drugs) TIER 1: Preferred Generic Drugs $0 $3 $0 $3 $0 $3 TIER 2: Generic Drugs $2 $7 $2 $7 $2 $7 TIER 3: Preferred Brand Drugs $40 $45 $40 $45 $40 $45 TIER 4: Non-Preferred Drugs $80 $85 $90 $95 $90 $95 TIER 5: Specialty Tier Drugs 33% 33% 33% 33% 33% 33% Coverage Gap Savings Opportunity Get a 3-month (90-day) supply of Tier 1 and Tier 2 drugs at either a Retail Pharmacy or SCAN Mail-Order and pay for only 2 months. The SCAN Story SCAN, a not-for-profit health plan, was founded in 1977 by seniors, for seniors. 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.
5 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 February 14) SCAN Classic (HMO), SCAN Balance (HMO SNP) and Heart First (HMO SNP) are HMO plans with Medicare contracts. Enrollment in SCAN Health Plan depends on contract renewal. You must continue to pay your Medicare Part B premium. SCAN Balance and Heart First are Coordinated Care Plans. SCAN Balance is available to anyone with Medicare who has been diagnosed with diabetes mellitus. Heart First is available to anyone with Medicare who has been diagnosed with congestive heart failure, cardiac arrhythmia, coronary artery disease, peripheral vascular disease or chronic venous thromboembolic disorder. This information is not a complete description of benefits. Contact the plan for more information. Benefits, premium, copayments and/or coinsurance may change on January 1 of each year. Limitations, copayments and restrictions may apply. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. Calling the agent number will direct you to a licensed insurance agent. You can get prescription drugs shipped to your home through our network automated mail-order delivery program. 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 s 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_10425_2017F File & Use Accepted G /17 18C-BHL101
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$100 Hospital Ambulatory Surgical Center (ASC) Specialist: $30/visit Chiropractic (Medicare-covered) Podiatry (Medicare-covered)
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