Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
Yes
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$4,000 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$24.00
Benefits
Service
Cost
Inpatient hospital coverage
$250 for days 1 through 6
$0 for days 7 through 90
$0 for days 7 through 90
Outpatient hospital coverage
$0-150 per visit
Doctor visits
Primary:
$0 copay
Specialist:
$0 copay
$0 copay
Specialist:
$0 copay
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$0 copay
$80 per visit (always covered)
Urgent care:
$0 copay
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$110
Outpatient x-rays:
$0 copay
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$110
Outpatient x-rays:
$0 copay
Mental health services
$250 for days 1 through 6
$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
$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
Skilled Nursing Facility
$0 for days 1 through 20
$100 for days 21 through 100
$100 for days 21 through 100
Rehabilitation services
Occupational therapy visit:
$10
Physical therapy and speech and language therapy visit:
$10
$10
Physical therapy and speech and language therapy visit:
$10
Ambulance
$230
Transportation
$0 copay
Foot care (podiatry services)
Foot exams and treatment:
$0 copay
Routine foot care:
$0 copay
$0 copay
Routine foot care:
$0 copay
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
$0 copay
Prosthetics (e.g., braces, artificial limbs):
$0 copay
Diabetes supplies:
$0 copay
$0 copay
Prosthetics (e.g., braces, artificial limbs):
$0 copay
Diabetes supplies:
$0 copay
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
20%
Other Part B drugs:
20%
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
Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment
Managing Chronic Conditions
Special needs plan care management
Care for older adults – medication review
Care for older adults – functional status assessment
Care for older adults – Pain screening
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions
Member Experience with Health Plan
Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination
Member Complaints, and Changes in Health Plan's Performance
Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement
Health Plan Customer Service
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical
Drug Plan Customer Service
Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld
Member Complaints, and Changes in Drug Plan's Performance
Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement
Member Experience with Drug Plan
Rating of drug plan
Getting needed prescription drugs
Drug Pricing and Patient Safety
MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate
Physician Finder
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