SCAN MyChoice (HMO)

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 – 0.00-125.00 Copay (Limits Apply)
• Endodontics
  • In-Network: No Coins – 5.00-395.00 Copay (Limits Apply)
• Oral and Maxillofacial Surgery
  • In-Network: No Coins – 0.00-140.00 Copay (Limits Apply)
• Periodontics
  • In-Network: No Coins – 0.00-380.00 Copay (Limits Apply)
• Prosthodontics, fixed
  • In-Network: No Coins – 25.00-395.00 Copay (Limits Apply)
• Prosthodontics, removable
  • In-Network: No Coins – 13.00-395.00 Copay (Limits Apply)
• Restorative Services
  • In-Network: No Coins – 8.00-395.00 Copay (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 – 0.00-5.00 Copay (Limits Apply)
• Other Preventive Dental Services
  • In-Network: No Coins – 0.00-80.00 Copay (Limits Apply)
• Prophylaxis (cleaning)
  • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

• Outpatient x-rays
  • $0 copay (Authorization Required, Referral Required)
• Diagnostic radiology services (e.g., MRI)
  • $60 copay (Authorization Required, Referral Required)
• Diagnostic tests and procedures
  • $0 copay (Authorization Required, Referral Required)
• Lab services
  • $0 copay (Authorization Required, Referral Required)

Doctor visits

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

Emergency care/Urgent care

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

Foot care (podiatry services)

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

Ground ambulance

• • $175 copay

Health plan deductible

• • $0

Hearing

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

Inpatient hospital coverage

• • $150 per day for days 1 through 7
    $0 per day for days 8 through 90 (Authorization Required, Referral Required)

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

• • $2,400 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

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

Mental health services

• Outpatient group therapy visit with a psychiatrist
  • $15 copay (Authorization Required, Referral Required)
• Outpatient group therapy visit
  • $25 copay (Authorization Required, Referral Required)
• Outpatient individual therapy visit
  • $25 copay (Authorization Required, Referral Required)
• Inpatient hospital – psychiatric
  • $900 per stay (Authorization Required, Referral Required)
• Outpatient individual therapy visit with a psychiatrist
  • $15 copay (Authorization Required, Referral Required)

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • $0-200 copay per visit (Authorization Required, Referral Required)

Preventive care

• • $0 copay (Authorization Required, Referral Required)

Rehabilitation services

• Occupational therapy visit
  • $15 copay (Authorization Required, Referral Required)
• Physical therapy and speech and language therapy visit
  • $15 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

• • $0 per day for days 1 through 20
    $125 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

• • Not covered

Vision

• 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)
• Contact 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

Dental PPO

Comprehensive Dental

• Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
  • Monthly Premium: $55.00
  • Max Coverage: $2000.00
  • Coverage Periodicity: Every year

Diagnostic and Preventive Dental

• Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services
  • Monthly Premium: $55.00
  • Max Coverage: $2000.00
  • Coverage Periodicity: Every year