Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.
Benefits, premiums and/or copayments/co‑insurance may change on January 1, 2023.
SUMMARY OF BENEFITS JANUARY 1, 2022 – DECEMBER 31, 2022
PREMIUM AND BENEFITS
WHAT YOU SHOULD KNOW
Monthly Health Plan Premium
You pay $0 per month
You must continue to pay your Medicare Part B premium.
Deductible
You pay $0
This plan does not have a deductible.
Maximum Out‑of‑Pocket Responsibility (this does not include prescription drugs)
$499 annually
The most you pay for copays and coinsurance for Medicare‑covered medical services for the year.
Inpatient Hospital Coverage
You pay $0
Our plan covers an unlimited number of days for an inpatient hospital stay. Prior authorization rules apply.
Outpatient Hospital Services
You pay $0 You pay $0
Prior authorization rules apply for outpatient hospital services.
Doctor Visits
You pay $0 You pay $0
Prior authorization rules apply for specialist visits.
Preventive Care
You pay $0
Any additional preventive services approved by Medicare during the contract year will be covered. Prior authorization rules apply.
Emergency Care
You pay $90 copay per visit
The emergency room copay will be waived if you are immediately admitted to the hospital. You are covered for worldwide emergency services.
Urgently Needed Services
You pay $0
You are covered for worldwide urgent care services.
You pay $0 You pay $0 You pay $0 You pay $50 copay per visit You pay $0
Prior authorization rules apply for diagnostic, lab, and imaging services.
Hearing Services Medicare‑covered diagnostic hearing and balance examNon‑Medicare‑covered (routine) hearing examNon‑Medicare‑covered (routine) hearing aids
You pay $0 You pay $0 for up to 1 visit every 12 months You pay $450 copay per aid for a TruHearing Advanced hearing aid or $750 copay per aid for a TruHearing Premium hearing aid You are covered for up to 2 hearing aids every 12 months
Prior authorization rules apply for Medicare‑covered diagnostic hearing and balance exams. You must go to a SCAN‑ contracted provider to obtain a routine hearing exam and hearing aids.
You pay $0 You pay $0 for up to 2 visits every 12 months You pay $0 for up to 2 visits every 12 months You pay $0 for up to 2 series every 12 months
Prior authorization rules apply for Medicare‑covered dental services.
PREMIUM AND BENEFITS
WHAT YOU SHOULD KNOW
Vision Services Medicare‑covered vision exam to diagnose/treat diseases of the eyeMedicare‑covered glasses after cataract surgeryNon‑Medicare‑covered (routine) vision examNon‑Medicare‑covered (routine) glasses or contact lensesNon‑Medicare‑covered (routine) vision coverage limit
You pay $0 You pay $0 You pay $0 for up to 1 visit every 12 months Included in the vision coverage limit You are covered for up to $250 for frames, lenses, and lens options or contact lenses every 24 months
Prior authorization rules apply for Medicare‑covered vision exam and glasses after cataract surgery. Routine vision services do not require prior authorization. You must go to a SCAN‑ contracted vision provider to obtain routine vision services.
Mental Health Services Inpatient visit Outpatient individual/group therapy visitOutpatient individual/ group therapy visit with a psychiatrist
You pay $0 for days 1‑90 You pay $0 You pay $0
Prior authorization rules apply for inpatient mental health hospitalization. You are covered for up to 90 days per benefit period.* Prior authorization rules apply for outpatient mental health services.
Skilled Nursing Facility
You pay $0 for days 1‑100
Prior authorization rules apply for skilled nursing facility services. You are covered for up to 100 days per benefit period.* No prior hospitalization is required.
Physical Therapy
You pay $0
Prior authorization rules apply for outpatient physical therapy services.
Ambulance
You pay $100 copay per one‑way trip
*A benefit period begins the day you go into a hospital or SNF. The benefit period ends when you haven’t received any inpatient hospital or SNF care for 60 days in a row.
PREMIUM AND BENEFITS
WHAT YOU SHOULD KNOW
Transportation (Non‑Medicare‑covered — routine)
You pay $0 for up to 34 one‑way trips per year You may use up to 16 of your 34 one‑way trips to non‑medical destinations (grocery store, health club, or senior center) per year. Specific criteria apply. 75‑mile limit applies to each one‑ way trip
Prior authorization rules apply for routine transportation services. You must use a SCAN‑contracted provider to obtain routine transportation services.
Medicare Part B Drugs
You pay 20% of the total cost for chemotherapy and other Part B drugs
Prior authorization rules apply to select drugs.
OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS):
You pay the following:
Drug Tier
Retail
Mail‑Order
Preferred
Standard
Preferred
Standard
30‑day supply
100‑day supply
30‑day supply
100‑day supply
100‑day supply
100‑day supply
Initial Coverage Stage
Tier 1 (Preferred Generic)
You pay $0
You pay $0
You pay $5
You pay $10
You pay $0
You pay $10
Tier 2 (Generic)
You pay $0
You pay $0
You pay $9
You pay $18
You pay $0
You pay $18
Tier 3 (Preferred Brand)
Select Insulins
You pay $25
You pay $55
You pay $35
You pay $85
You pay $55
You pay $85
Other Drugs
You pay $37
You pay $91
You pay $47
You pay $121
You pay $91
You pay $121
Tier 4 (Non‑Preferred Drug)
You pay $95
You pay $265
You pay $100
You pay $280
You pay $265
You pay $280
Tier 5 (Specialty Tier)
You pay 33%
Not available
You pay 33%
Not available
Not available
Not available
These copays for select insulins apply to members who do not qualify for a program that helps pay for your drugs (“Extra Help”). Select insulins are all insulin pens and vials in Tier 3 covered on our most recent Drug List we provided electronically. If you have questions about the Drug List, you can call Member Services.
Some of our network pharmacies have preferred cost‑sharing. You may pay less for certain drugs if you use these pharmacies. Your cost‑sharing may vary depending on the pharmacy you choose (e.g., Preferred Retail, Standard Retail, Preferred Mail‑Order, Standard Mail‑Order, Long Term Care (LTC), Home infusion, etc.) or whether you receive a one‑month or a three‑month supply or when you enter another phase of the Part D benefit or if you receive “Extra Help.” For more information, please call our Member Services Department at the number provided in this document or access your Evidence of Coverage online. If you reside in a long‑ term care facility, your cost‑sharing for a 31‑day supply is the same as at a standard retail pharmacy for a 30‑day supply. You may get drugs from an out‑of‑network pharmacy, but may pay more than you pay at an in‑network pharmacy.
You can get prescription drugs shipped to your home through our network mail‑order delivery program. Express Scripts PharmacySM is our Preferred mail‑order pharmacy. While you can fill your prescription medications at any of our network mail‑order pharmacies, you may pay less at the Preferred mail‑order pharmacy. Typically, you should expect to receive your prescription drugs within 14 days from the time that Express Scripts 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. For your mail‑order prescriptions, you have the option to sign up for an automatic refill program by contacting Express Scripts Pharmacy at 1‑866‑553‑4125, 24 hours a day, 7 days a week. TTY users call 711. You may opt out of automatic deliveries at any time. Other pharmacies are available in our network.
ADDITIONAL BENEFITS
Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.
BENEFITS
SCAN HEART FIRST
WHAT YOU SHOULD KNOW
Acupuncture Services (routine)
You pay $5 copay per visit
You do not need a referral for an initial acupuncture visit. Any subsequent visits require prior authorization.
Chiropractic Services Medicare‑covered chiropractic careRoutine chiropractic care
You pay $0 You pay $5 copay per visit
Prior authorization rules apply You do not need a referral for an initial routine chiropractor visit. Any subsequent visits require prior authorization.
Home Health Care (Medicare‑covered)
You pay $0
Prior authorization rules apply
Medical Equipment/Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen)Prosthetics (e.g., braces, artificial limbs)Diabetic supplies
You pay 0%‑20% of the total cost You pay 0%‑20% of the total cost You pay $0
Prior authorization rules apply for covered durable medical equipment, prosthetic devices, and certain diabetic supplies. SCAN covers diabetic supplies such as glucose monitors, test strips, and control solution from a select manufacturer. Lancets are also covered and are available from all manufacturers.
BENEFITS
SCAN HEART FIRST
WHAT YOU SHOULD KNOW
Telehealth Services (MDLive)
You pay $0
A visit with a board‑certified doctor in the comfort of your own home. This benefit is for non‑life‑threatening conditions such as, but not limited to, cough, flu, nausea, sore throat, fever, and allergies. Visits with doctors can be conducted either by telephone or secure video capabilities from your computer or smart phone.
Over‑the‑Counter (OTC) Products
You are covered for up to $50 per quarter
You are covered up to 2 shipments per quarter and any remaining balance is carried over to the next quarter. The benefit does not carry over to the next calendar year.
SCAN Heart First has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.
ABOUT SCAN HEART FIRST
Who can join?
You must: have both Medicare Part A and Part Blive in the plan service area (Orange County, California)be a United States citizen or be lawfully present in the United Statesbe diagnosed with cardiovascular disorders and/or chronic heart failure
Phone Number (Members)
1‑800‑559‑3500
Phone Number (Non‑Members)
1‑877‑870‑4867
Calling this number will direct you to a licensed insurance agent.
TTY
711
Hours of Operation
October 1 to March 31: 8 a.m. to 8 p.m., 7 days a week April 1 to September 30: 8 a.m. to 8 p.m., Monday through Friday Messages received on holidays and outside of our business hours will be returned within one business day.
To get more information about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at https://www.medicare.gov or get a copy by calling 1‑800‑MEDICARE (1‑800‑633‑4227), 24 hours a day, 7 days a week. TTY users call 1‑877‑486‑2048. This information is not a complete description of benefits. Call 1‑800‑559‑3500 (TTY: 711) for more information. You can get prescription drugs shipped to your home through our network mail‑order delivery program, which is called Express Scripts Pharmacy.SM 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 at 1‑800‑559‑3500, 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day). TTY: 711.
