SCAN Essential Savings (HMO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: SCAN Health Plan
- Rx
- Dental
- Vision
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $15 copay
Out-of-network: $0 copay
Emergency Room
$90 copay
Ambulance Coverage
In-network: $125 copay
Out-of-network: $125 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $5 copay
Out-of-network: $5 copay
Lab services:
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$75 copay
Out-of-network: $0-$75 copay
Outpatient x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Hospital Services
Inpatient hospital coverage:
Tier 1
$50 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Outpatient hospital coverage:
In-network: $15-$225 copay
Out-of-network: $15-$225 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $15 copay
Out-of-network: $15 copay
Urgent Care Coverage
$90 copay
Skilled Nursing Facility (SNF)
Tier 1
$0 per day for days 1-20
$100 per day for days 21-100
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $20 copay
Out-of-network: $20 copay
Outpatient individual therapy with a psychiatrist:
In-network: $20 copay
Out-of-network: $20 copay
Outpatient group therapy visits:
In-network: $20 copay
Out-of-network: $20 copay
Outpatient individual therapy visit:
In-network: $20 copay
Out-of-network: $20 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$126.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$43.00 copay (30-day supply)
$129.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$43.00 copay (30-day supply)
$129.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$126.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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