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SCAN Allied (HMO)

H5425 - 122 - 0
4.5 out of 5 stars (4.5 / 5)

SCAN Allied (HMO) is a Medicare Advantage Plan by SCAN Health Plan.

This page features plan details for 2025 SCAN Allied (HMO) H5425 – 122 – 0 available in San Mateo County.

Locations

SCAN Allied (HMO) is offered in the following locations.

California
San Mateo County, California

Click to see more locations

Plan Overview

SCAN Allied (HMO) offers the following coverage and cost-sharing.

Insurer:SCAN Health Plan
Health Plan Deductible:$0
MOOP:$2,200 In-network
Drugs Covered:Yes

Ready to sign up for SCAN Allied (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

SCAN Allied (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

SCAN Allied (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

SCAN Allied (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • $0 copay (Authorization Required, Referral Required)
  • Lab services
    • $0 copay (Authorization Required, Referral Required)
  • Outpatient x-rays
    • $0 copay (Authorization Required, Referral Required)
  • Diagnostic radiology services (e.g., MRI)
    • $0 copay (Authorization Required, Referral Required)

Doctor visits

  • Specialist
    • $10 copay per visit (Authorization Required, Referral Required)
  • Primary
    • $0 copay

Emergency care/Urgent care

  • Urgent care
    • $0 copay
  • Emergency
    • $140 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • $10 copay
  • Routine foot care
    • Not covered

Ground ambulance

    • $180 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • $0 copay (Authorization Required, Referral Required)
  • Medicare-Covered Hearing Exam
    • $10 copay (Authorization Required, Referral Required)
  • Hearing aids OTC
    • Not covered
  • Hearing aids
    • $550-850 copay (Limits Apply)

Inpatient hospital coverage

    • $175 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $2,200 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • 0-20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • $0 copay (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient individual therapy visit
    • $15 copay (Authorization Required, Referral Required)
  • Outpatient group therapy visit with a psychiatrist
    • $15 copay (Authorization Required, Referral Required)
  • Outpatient group therapy visit
    • $15 copay (Authorization Required, Referral Required)
  • Outpatient individual therapy visit with a psychiatrist
    • $15 copay (Authorization Required, Referral Required)
  • Inpatient hospital – psychiatric
    • $250 per day for days 1 through 6
      $0 per day for days 7 through 90 (Authorization Required, Referral Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $0-125 copay per visit (Authorization Required, Referral Required)

Preventive care

    • $0 copay (Authorization Required, Referral Required)

Rehabilitation services

  • Occupational therapy visit
    • $0 copay (Authorization Required, Referral Required)
  • Physical therapy and speech and language therapy visit
    • $0 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $75 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

    • $0 copay (Limits Apply)

Vision

  • Eyeglass lenses
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Eyeglass frames
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Other
    • Not covered
  • Routine eye exam
    • $0 copay (Limits Apply, Authorization Required, Referral Required)
  • Upgrades
    • Not covered
  • Contact lenses
    • $0 copay (Limits Apply, Authorization Required, Referral Required)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for SCAN Allied (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on SCAN Allied (HMO)? See 2025 SCAN Allied (HMO) at MedicareAdvantageRX.com.

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