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SCAN Prime (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for SCAN Prime (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on SCAN Prime (HMO) in 2026, please refer to our full plan details page.
SCAN Prime (HMO) is a HMO plan offered by SCAN Group available for enrollment in 2025 to people living in Select Southern CA Counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that SCAN Prime (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about SCAN Prime (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For SCAN Prime (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $20.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $250.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2499.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The SCAN Prime (HMO) Medicare Advantage plan features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $250.00. During the initial coverage phase, members enjoy no copay for Tier 1 preferred generic drugs when using a preferred pharmacy or preferred mail-order service. Standard generic drugs carry a $42.00 copay at preferred locations, while Tier 3 preferred brands and Tier 4 non-preferred drugs require 35% and 30% coinsurance, respectively. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Medicare Part D prescriptions. Additionally, individuals who qualify for the low-income subsidy, or Extra Help, will benefit from a reduced Part D premium of $0.00. Be sure to check the plan's formulary to verify how your specific prescriptions are classified across these tiers.
Additional Benefits
The SCAN Prime (HMO) plan offers robust health coverage with low out-of-pocket costs for essential medical services. For inpatient hospital stays, members pay a $100 daily copay for the first three days and no copay for days four through 90. Additionally, emergency room visits carry a $120 copay, which is waived if admitted, while urgently needed care and preventive services are available with no copay. This plan also includes valuable supplemental benefits like dental, vision, hearing, and wellness perks. Members receive routine vision and hearing exams with no copay, a $200 annual eyewear allowance, and up to $4,000 annually for covered dental care. Furthermore, the plan provides a $50 quarterly over-the-counter allowance and a meal benefit with no copay to support your daily health needs.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by SCAN Prime (HMO) with a $100 daily copay for days 1 through 3, no copay for days 4 through 90, and no coinsurance for both acute and psychiatric stays. Prior authorization and doctor referrals are required, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by SCAN Prime (HMO), including outpatient hospital, ambulatory surgical, and blood services, for which specific copay and coinsurance details are not specified. Outpatient substance abuse services are covered with a $10 copay and no coinsurance for both individual and group sessions.
Partial Hospitalization See details
SCAN Prime (HMO) partial hospitalization benefits are covered with a $10.00 copay and no coinsurance. Prior authorization and a doctor referral are required to access these services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by SCAN Prime (HMO), with ground and air ambulance services requiring a $200 copay and no coinsurance. Transportation services to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
Emergency services are covered under SCAN Prime (HMO) with a $120 copay and no coinsurance, and this copay is waived if you are admitted to the hospital. Urgently needed services are covered with no copay and no coinsurance, while worldwide emergency coverage and emergency transportation are covered with copays of $120 and $200, respectively, and no coinsurance.
Primary Care See details
SCAN Prime (HMO) partially covers Primary Care benefits, featuring a $10 copay and no coinsurance for opioid treatment services. While some psychiatric and mental health specialty services are covered, podiatry, routine chiropractic care, and individual or group sessions for mental health and psychiatric services are not covered.
Preventive Services See details
Preventive services are partially covered by SCAN Prime (HMO) with no copay or coinsurance for Medicare-covered zero-dollar preventive services, annual physical exams, and kidney disease education. However, sub-services such as in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, additional smoking cessation, disease management, telemonitoring, home safety modifications, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by SCAN Prime (HMO), including one annual routine hearing exam and fitting evaluations with no deductible. Prescription hearing aids (all types) are covered up to two per year with a copay of $550 to $850 and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by SCAN Prime (HMO), offering one routine eye exam per year and a $200 annual eyewear allowance with no deductible, though upgrades are not covered. Prior authorization and a doctor referral are required for these benefits.
Dental Services See details
Dental services are covered by SCAN Prime (HMO), though the benefit is partially covered as orthodontics is not covered. While specific copay and coinsurance amounts are not specified, the plan provides up to a $4,000 annual maximum for other covered services in the orthodontic category, with prior authorization required for most comprehensive procedures.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by SCAN Prime (HMO) with prior authorization, requiring no copay and coinsurance ranging from no coinsurance to 20% for chemotherapy, radiation, and other Part B drugs. Covered Medicare Part B insulin drugs require a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
SCAN Prime (HMO) covers dialysis services with a $25 copay and no coinsurance. Prior authorization and a doctor referral are required to access this benefit.
Medical Equipment See details
SCAN Prime (HMO) covers Durable Medical Equipment (DME) with prior authorization, though copay and coinsurance information is not specified. For prosthetics and diabetic equipment, some services are covered, but prosthetic devices, medical supplies, diabetic supplies, and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by SCAN Prime (HMO), which offers therapeutic radiological services with a $50 copay and no coinsurance. Other services under this benefit, including diagnostic procedures, lab services, diagnostic radiological services, and outpatient X-ray services, are not covered.
Home Health Services See details
Home health services are covered under the SCAN Prime (HMO) plan, requiring a doctor referral and prior authorization before receiving care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the SCAN Prime (HMO) plan, meaning there is no coverage, copay, or coinsurance for cardiac, intensive cardiac, pulmonary, or supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by SCAN Prime (HMO), which covers standard Medicare-covered days without requiring a prior three-day inpatient hospital stay. Prior authorization and a doctor referral are required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
SCAN Prime (HMO) partially covers Other Services, offering a meal benefit and a $50 quarterly over-the-counter allowance with no copay and no coinsurance. Acupuncture and Dual Eligible SNPs with Highly Integrated Services are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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