Scripps Classic offered by SCAN Health Plan (HMO)
H5425 - 005 - 0
(3.5 / 5)
Scripps Classic offered by SCAN Health Plan (HMO) is a Medicare Advantage Plan by SCAN Health Plan.
This page features plan details for 2024 Scripps Classic offered by SCAN Health Plan (HMO) H5425 – 005 – 0 available in San Diego County.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Scripps Classic offered by SCAN Health Plan (HMO) is offered in the following locations.
Plan Overview
Scripps Classic offered by SCAN Health Plan (HMO) offers the following coverage and cost-sharing.
| Insurer: | SCAN Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,400 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Scripps Classic offered by SCAN Health Plan (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
Scripps Classic offered by SCAN Health Plan (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 |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $0.00 | $ |
- 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
Scripps Classic offered by SCAN Health Plan (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
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 | $ |
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 $5,030.00. 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) | $0.00 copay | $9.00 copay | $0.00 copay | $9.00 copay |
| 2 (Generic) | $5.00 copay | $15.00 copay | $5.00 copay | $15.00 copay |
| 3 (Preferred Brand) | $42.00 copay | $47.00 copay | $42.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $95.00 copay | $100.00 copay | $95.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
| 6 (Select Care Drugs) | $11.00 copay | $11.00 copay | $11.00 copay | $11.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $18.00 copay | $0.00 copay | $18.00 copay |
| 2 (Generic) | $10.00 copay | $30.00 copay | $0.00 copay | $30.00 copay |
| 3 (Preferred Brand) | $106.00 copay | $121.00 copay | $106.00 copay | $121.00 copay |
| 4 (Non-Preferred Drug) | $265.00 copay | $280.00 copay | $265.00 copay | $280.00 copay |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $33.00 copay | $33.00 copay | $33.00 copay | $33.00 copay |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $9.00 copay | $0.00 copay | $9.00 copay |
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $18.00 copay | $0.00 copay | $18.00 copay |
| Generic drugs | ||||
| Brand-name drugs |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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
Scripps Classic offered by SCAN Health Plan (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,400 In-network |
| Yes |
| In-network | No |
| $35-300 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $35 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is required.) (Referral is required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $30 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $50 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $10 copay (Authorization is required.) (Referral is required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Hearing aids | $450-750 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Cleaning | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $40 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is required.) |
| $240 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $295 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $250 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit | $20 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit | $20 copay (Authorization is required.) (Referral is required.) |
| $0 per day for days 1 through 20 $140 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
| Monthly Premium | $6.00 |
| Deductible | nan |
| Monthly Premium | $16.00 |
| Deductible | nan |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $6.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $6.00 |
| Comprehensive dental: | Deductible: | N/A |
Package #2
| Preventive dental: | Monthly Premium: | $16.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $16.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Scripps Classic offered by SCAN Health Plan (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
Table of Contents
Need more information on Scripps Classic offered by SCAN Health Plan (HMO)? See 2025 Scripps Classic offered by SCAN Health Plan (HMO) at MedicareAdvantageRX.com.
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SMID: MULTIPLAN_HCIHNDOGMED01PY25_M
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