Scripps Plus offered by SCAN Health Plan (HMO)
Scripps Plus offered by SCAN Health Plan (HMO) H5425-040 Plan Details
Scripps Plus offered by SCAN Health Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5425-040.
$33.20
Monthly Premium
Scripps Plus offered by SCAN Health Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5425-040.
California Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $480 |
| Out of Pocket Max |
In-Network: $7550 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $0.00 per day for days 1 to 60 $335.00 per day for days 61 to 90 Deductible $1340.00 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Coinsurance for Urgent Care 20% Worldwide Coverage: Coinsurance for Worldwide Urgent Coverage 20% |
| Emergency Room Visit | Coinsurance for Emergency Care 20% Worldwide Coverage: Coinsurance for Worldwide Emergency Coverage 20% Coinsurance for Worldwide Emergency Transportation 20% |
| Ambulance Transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Air Ambulance: Coinsurance for Air Ambulance Services 20% Paramedic Intercept services are not covered by the Plan except when they would be covered by Original Medicare. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
Scripps Plus offered by SCAN Health Plan (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Coinsurance for Medicare-covered Chiropractic Services 20% Copayment for Routine Care $5.00
Referral Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Coinsurance for Medicare-covered X-Ray Services 20% Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Referral Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $0.00 per day for days 1 to 60 $341.00 per day for days 61 to 90 Deductible $1364.00 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services Referral Required for Outpatient Mental Health Services Prior authorization required |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 20% Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 20% Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $85.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Coinsurance for Medicare-Covered Podiatry Services 20% Copayment for Routine Foot Care $0.00
Referral Required for Podiatry Services Prior authorization required |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $170.50 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Coinsurance for Medicare-covered Benefits 20% Copayment for Diagnostic Services $0.00
Prior Authorization Required for Comprehensive Dental Referral Required for Comprehensive Dental Prior authorization required |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Coinsurance for Medicare Covered Benefits 20% Copayment for Routine Eye Exams $0.00
Referral Required for Eye Exams Eyewear: Coinsurance for Medicare-Covered Benefits 20% Copayment for Contact Lenses $0.00
Prior Authorization Required for Eyewear Referral Required for Eyewear Prior authorization required |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 20% Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Prior authorization required |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Scripps Plus offered by SCAN Health Plan (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $480 (excludes Tier 1) per year.
| Coverage |
Cost
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|---|---|
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Coverage & Cost
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| Annual Drug Deductible | $480 (excludes Tier 1) |
| Preferred Generic |
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| Annual Drug Deductible | $480 (excludes Tier 1) |
| Preferred Generic |
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| Annual Drug Deductible | $480 (excludes Tier 1) |
| Preferred Generic |
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