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SCAN Health Plan

Plan ID: H5425-66-0

SCAN Prime (HMO)

2024 SCAN Prime (HMO) H54250660 is a Medicare Advantage plan with drug coverage. It has received a 3.5-out-of-5 star rating from CMS for 2024.

Learn more about SCAN Prime (HMO) H5425 - 066 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

3.5 / 5 stars for 2024

$26.00 /mo

Monthly premium

$0

Health deductible

$0

Drug deductible

$299.00

Out-of-pocket maximum

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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week!

Overview Icon

Plan Overview

2024 SCAN Prime (HMO) H54250660 is a Local HMO offered in Orange County by SCAN Health Plan. It has a monthly premium of $26.00.

Premium Breakdown

Standard Part B Premium

$174.70

Part B premium reduction

- $0

Monthly Plan Premium

$26.00

Total Premium:

$200.70

Note:

The standard Part B premium for 2024 is $174.70. Your Part B premium may differ based on factors including late enrollment, income, and disability status. Higher-income beneficiaries may pay an income-related monthly adjustment amount (IRMAA). The Part B premium is required to be paid by everyone enrolled in Medicare Part B.

Special needs plan type

No

Out-of-pocket maximum

$299.00

Plan Organization:

SCAN Health Plan

Plan Type:

Local HMO

Location:

Orange County

Drugs Covered:

Yes

Drug Formulary:

Pharmacies:

Doctor Choice:

Plan Doctors for Most Services

Doctors Link:

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

$0

Drug deductible

$0

Sign up for SCAN Prime (HMO)

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Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage Icon

Drug Coverage

SCAN Prime (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced

Prescription drug deductible

$0

Increased initial coverage limit

No

Additional gap coverage

Yes

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D

LIS 25%

LIS 50%

LIS 75%

LIS Full

$0.00

$0.00

$0.00

$0.00

$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

30 Days
60 Days
90 Days

Tier

Preferred Pharmacy

Standard Pharmacy

Preferred Mail

Standard Mail

1. Preferred Generic

$0.00 copay

$5.00 copay

$0.00 copay

$5.00 copay

2. Standard Generic

$0.00 copay

$12.00 copay

$0.00 copay

$12.00 copay

3. Preferred Brand

$35.00 copay

$47.00 copay

$35.00 copay

$47.00 copay

4. Non-Preferred Drug

$95.00 copay

$100.00 copay

$95.00 copay

$100.00 copay

5. Specialty Tier

33%

33%

33%

33%

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

30 Days
60 Days
90 Days

Tier

Preffered Pharmacy

Standard Pharmacy

Preffered Mail

Standard Mail

Preferred Generic

$0.00 copay

$5.00 copay

$0.00 copay

$5.00 copay

Generic

$0.00 copay

$12.00 copay

$0.00 copay

$12.00 copay

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Generic Drugs

$4.15 copay or 5% (whichever costs more)

Brand-name

$10.35 copay or 5% (whichever costs more)

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Additional Benefits

SCAN Prime (HMO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Additional Coverage Icon

Comprehensive dental

Non-routine services
$0-125 copay
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Diagnostic services
$0-5 copay
Limit IconExclamation Icon
Restorative services
$8-395 copay
Limit IconExclamation Icon
Endodontics
$5-395 copay
Limit IconExclamation Icon
Periodontics
$0-380 copay
Limit IconExclamation Icon
Extractions
$0-140 copay
Limit IconExclamation Icon
Prosthodontics, other oral/maxillofacial surgery, other services
$13-395 copay
Limit IconExclamation Icon
Additional Coverage Icon

Preventive dental

Oral exam
$0 copay
Limit Icon
Cleaning
$0 copay
Limit Icon
Fluoride treatment
Not covered
Limit Icon
Dental x-ray(s)
$0 copay
Limit Icon
Additional Coverage Icon

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures
$0 copay
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Lab services
$0 copay
Exclamation IconReferral Icon
Diagnostic radiology services (eg, MRI)
$0 copay
Exclamation IconReferral Icon
Outpatient x-rays
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Doctor visits

Primary
$0 copay
Specialist
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Emergency care/Urgent care

Emergency
$90 copay per visit (always covered)
Urgent care
$0 copay
Additional Coverage Icon

Foot care (podiatry services)

Foot exams and treatment
$0 copay
Routine foot care
Not covered
Additional Coverage Icon

Ground ambulance

Service
$100 copay
Additional Coverage Icon

Hearing

Hearing exam
$0 copay
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Fitting/evaluation
$0 copay
Limit IconExclamation IconReferral Icon
Hearing aids
$200-400 copay
Limit Icon
Additional Coverage Icon

Inpatient hospital coverage

Service
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Outpatient hospital coverage

Service
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Outpatient prescription drugs

SCAN Prime (HMO) does not provide this type of benefit.

Additional Coverage Icon

Optional benefits

SCAN Prime (HMO) does not provide this type of benefit.

Additional Coverage Icon

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)
0-20% coinsurance per item
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Prosthetics (eg, braces, artificial limbs)
0-20% coinsurance per item
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Diabetes supplies
$0 copay
Exclamation Icon
Additional Coverage Icon

Medicare Part B drugs

Chemotherapy
0-20% coinsurance
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Other Part B drugs
0-20% coinsurance
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Part B Insulin drugs
0-20% coinsurance (up to $35)
Exclamation Icon
Additional Coverage Icon

Mental health services

Inpatient hospital - psychiatric
$0 copay
Exclamation IconReferral Icon
Outpatient group therapy visit with a psychiatrist
$0 copay
Exclamation IconReferral Icon
Outpatient individual therapy visit with a psychiatrist
$0 copay
Exclamation IconReferral Icon
Outpatient group therapy visit
$0 copay
Exclamation IconReferral Icon
Outpatient individual therapy visit
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Preventive care

Service
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Rehabilitation services

Occupational therapy visit
$0 copay
Exclamation IconReferral Icon
Physical therapy and speech and language therapy visit
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Skilled Nursing Facility

Service
$0 copay
Exclamation IconReferral Icon
Additional Coverage Icon

Transportation

Service
$0 copay
Limit Icon
Additional Coverage Icon

Vision

Routine eye exam
$0 copay
Limit IconExclamation IconReferral Icon
Other
Not covered
Limit Icon
Contact lenses
$0 copay
Limit IconExclamation IconReferral Icon
Eyeglasses (frames and lenses)
$0 copay
Limit IconExclamation IconReferral Icon
Eyeglass frames
$0 copay
Limit IconExclamation IconReferral Icon
Eyeglass lenses
$0 copay
Limit IconExclamation IconReferral Icon
Upgrades
Not covered
Additional Coverage Icon

Wellness programs (eg, fitness, nursing hotline)

Service
Covered
Overview Icon

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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Get Personalized Help from a licensed insurance agent

1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

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