2018 Benefit Highlights
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1 Los Angeles, Riverside and San Bernardino Counties 2018 Benefit Highlights SCAN Connections (HMO SNP) Medicare Advantage Plan
2 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. Additional Benefits And Services Vision Services (Routine) Eye Exam Glasses or Contact Lenses Coverage for Frames or Contacts Dental Services (Routine) Dental Exams Dental Cleanings Dental X-rays $0 (1 per year) $0 (every 2 years) $300 (every 2 years) $0 (2 per year) $0 (2 per year) $0 (1 every 6 months) Transportation (Routine) $0* Hearing Services (Routine) Hearing Exam Hearing Aid Copay Acupuncture Services (Routine) Chiropractic Services (Routine) Podiatry Services (Routine) (e.g., toenail trimming, callus removal) Over-the-Counter Items** Like aspirin, vitamins, hydrocortisone, etc. See SCAN website for details $0 (1 per year) $0 (per aid/per year) $0 (24 visits per year) $10 (10 visits per year) $0 (6 visits per year) $0 Incontinence Supplies (e.g., diapers/pads) $0 Bathroom Safety Equipment (e.g., grab bars, bath benches) $0 (criteria and limitations apply) Health Club Membership $0 Home-Delivered Meals Personal Emergency Response System $0 (criteria and limitations apply) $15 per month (one-time installation fee of $25 applies) * 75-mile limit will apply to each one-way trip
3 For people with Medicare and Medi-Cal who are 65 or older. SCAN Connections works to help members get the most out of their Medicare and Medi-Cal benefits. SCAN PAL (Personal Assistance Line) As a SCAN Connections member, you will have your own PAL specialist. Your specialist can help you with things like: Making appointments Questions about your benefits Medical billing Scheduling transportation SCAN Connections was designed for people who have both Medicare and Medi-Cal. Connections gives you: All your Medicare benefits All your Medi-Cal benefits Plus drug coverage Plus extra benefits Having your Medicare and Medi-Cal enrolled in a single health plan makes it simple for both you and your doctor. All-in-one easy-to-use plan! And if you ever have questions about any of your benefits, SCAN is here to help. Your PAL specialist is here to help you get the services you need.
4 Plan Details Monthly Plan Premium $0 Annual Plan Deductible $0 Comprehensive Care Primary Care Office Visits $0 Specialist Office Visits $0 Diabetic Self-Management Training $0 Diabetic Supplies (Lancets, Test Strips, Monitor) $0 Annual Physical Exam $0 Preventive Services (Medicare-Covered Screenings) $0 Lab Services and X-rays $0 Diagnostic Tests and Procedures $0 Outpatient Rehabilitation (e.g., PT, OT, ST) $0 Durable Medical Equipment $0 Diagnostic Radiology (e.g., MRI, CT) $0 Outpatient Mental Health (Individual/Group) $0 Psychiatric Services (Individual/Group) $0 Hospital and Emergency Care Inpatient Hospital Care $0 Skilled Nursing Facility $0 Outpatient Surgery $0 Emergency Care Urgent Care Services Ambulance Services $0 (worldwide) $0 (worldwide) $0 (per one-way trip) Maximum Out-of-Pocket Annual Maximum Out-of-Pocket (MOOP) $0
5 Prescription Drug Coverage Pharmacy Network Preferred Standard Part D Deductible (Tiers 2-5) $0 $0 Initial Coverage Stage SCAN-Contracted Pharmacy (1-month/30-day Supply of Drugs) TIER 1: Preferred Generic Drugs $0 $0 or $1.25 or $3.35 TIER 2: Generic Drugs TIER 3: Preferred Brand Drugs TIER 4: Non-Preferred Drugs TIER 5: Specialty Tier Drugs $0 or $1.25 or $3.35 $0 or $1.25 or $3.35 or $3.70 or $8.35 $0 or $1.25 or $3.35 $0 or $1.25 or $3.35 or $3.70 or $8.35
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 February 14) SCAN Connections (HMO SNP) is an HMO plan with a Medicare contract and a contract with the California Medi-Cal (Medicaid) program. Enrollment in SCAN Health Plan depends on contract renewal. You must continue to pay your Medicare Part B premium. Part B premiums may be covered by Medi-Cal depending on your level of eligibility. SCAN Connections is available to anyone who has assistance from both the state of California (Medi-Cal) and Medicare. SCAN Connections is a Coordinated Care Plan. 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. 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_10426_2017F File & Use Accepted G /17 18C-BHL006
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