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SCAN Balance (HMO C-SNP)

H5425 - 076 - 0

(4.5 / 5)

SCAN Balance (HMO C-SNP) is a Medicare Advantage Special Needs Plan by SCAN Health Plan.

This page features plan details for 2025 SCAN Balance (HMO C-SNP) H5425 – 076 – 0 available in Alameda and San Mateo Counties.

Locations

SCAN Balance (HMO C-SNP) is offered in the following locations.

Alameda County, California

California

San Mateo County, California

Click to see more locations

Plan Overview

SCAN Balance (HMO C-SNP) offers the following coverage and cost-sharing.

Special Needs Plan Type:	Chronic or Disabling Condition
Conditions Covered:	CardiovascularDisorders, ChronicHeartFailure, DiabetesMellitus

Insurer:	SCAN Health Plan
Health Plan Deductible:	$0
MOOP:	$1,500 In-network
Drugs Covered:	Yes

Ready to sign up for SCAN Balance (HMO C-SNP) ?

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 Balance (HMO C-SNP) 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 Balance (HMO C-SNP) 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 D	LIS 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.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$5.00 Copay		$5.00 Copay
2) Generic		$10.00 Copay		$10.00 Copay
3) Preferred Brand	$42.00 Copay	$47.00 Copay	$42.00 Copay	$47.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$10.00 Copay		$10.00 Copay
2) Generic		$20.00 Copay		$20.00 Copay
3) Preferred Brand	$84.00 Copay	$94.00 Copay	$84.00 Copay	$94.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$10.00 Copay		$10.00 Copay
2) Generic		$20.00 Copay		$20.00 Copay
3) Preferred Brand	$126.00 Copay	$141.00 Copay	$126.00 Copay	$141.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

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

Doctor visits

Primary
- $0 copay
Specialist
- $0 copay (Authorization Required, Referral Required)

Emergency care/Urgent care

Urgent care
- $0 copay
Emergency
- $90 copay per visit (always covered)

Foot care (podiatry services)

Routine foot care
- Not covered
Foot exams and treatment
- $0 copay

Ground ambulance

- $180 copay

Health plan deductible

- $0

Hearing

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

Inpatient hospital coverage

- $100 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)

- $1,500 In-network

Medical equipment/supplies

Diabetes supplies
- $0 copay (Authorization Required)
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)

Medicare Part B drugs

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

Mental health services

Inpatient hospital – psychiatric
- $250 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required, Referral Required)
Outpatient group therapy visit
- $10 copay (Authorization Required, Referral Required)
Outpatient individual therapy visit
- $10 copay (Authorization Required, Referral Required)
Outpatient group therapy visit with a psychiatrist
- $10 copay (Authorization Required, Referral Required)
Outpatient individual therapy visit with a psychiatrist
- $10 copay (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

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

Contact 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)
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply, Authorization Required, Referral Required)
Eyeglass lenses
- $0 copay (Limits Apply, Authorization Required, Referral Required)
Upgrades
- Not covered

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

- Covered