Plan Details
Costs and Other Important Information
Benefits
$0 for days 7 through 90
$0 copay
Specialist:
$0 copay
$80 per visit (always covered)
Urgent care:
$0 copay
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$110
Outpatient x-rays:
$0 copay
$0 for days 7 through 90
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$30
Outpatient individual therapy visit:
$30
$100 for days 21 through 100
$10
Physical therapy and speech and language therapy visit:
$10
$0 copay
Routine foot care:
$0 copay
$0 copay
Prosthetics (e.g., braces, artificial limbs):
$0 copay
Diabetes supplies:
$0 copay
20%
Other Part B drugs:
20%
Coverage Area for SCAN Classic II (HMO)
State | California |
---|---|
County | Los Angeles |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $0 copay | $5 copay | Not offered |
Tier 2: Non-Preferred Generic | $5 copay | $10 copay | Not offered |
Tier 3: Preferred Brand Name | $42 copay | $47 copay | Not offered |
Tier 4: Non-Preferred Brand Name | $95 copay | $100 copay | Not offered |
Tier 5: Specialty Tier | 33% coinsurance | 33% coinsurance | Not offered |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $0 copay | $0 copay | Not offered |
Tier 2: Non-Preferred Generic | $10 copay | $20 copay | Not offered |
Tier 3: Preferred Brand Name | $116 copay | $131 copay | Not offered |
Tier 4: Non-Preferred Brand Name | $275 copay | $290 copay | Not offered |
Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept SCAN Classic II (HMO) for California