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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 2025, 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 4.5 out of 5 stars in 2025.
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 $22.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $299.00 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) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay different copays or coinsurance amounts depending on the drug tier and where you get your prescription filled. For example, you will pay no copay for preferred generic drugs at a preferred pharmacy. After your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for covered drugs. This plan may also reduce your premium if you qualify for the low-income subsidy.
Additional Benefits
The SCAN Prime (HMO) plan offers a wide range of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the service. Emergency services and ambulance services are covered, but have copays of $90 and $200, respectively. Preventive services and routine eye exams have no copay. This plan also includes coverage for hearing services, with a maximum benefit for hearing aids, and dental services, with copays varying by service type. Additional benefits include coverage for home infusion services, dialysis, and medical equipment, along with some other services such as acupuncture and over-the-counter items. However, some services, such as certain mental health services and home health services, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric services, are covered with prior authorization and a doctor referral. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, as well as Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric, are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered by SCAN Prime (HMO). Individual and group sessions for outpatient substance abuse have a copay of $10.00.
Partial Hospitalization See details
Partial Hospitalization is covered under the SCAN Prime (HMO) plan with a $10 copay, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $200 copay for both ground and air ambulance services, and no coinsurance. Transportation Services to a plan-approved health-related location are covered for up to 44 one-way trips per year using rideshare services, bus/subway, or medical transport, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by SCAN Prime (HMO). Emergency Services and Worldwide Emergency Coverage have a $90 copay, and Worldwide Emergency Transportation has a $200 copay.
Primary Care See details
The SCAN Prime (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are covered, but require prior authorization and a doctor referral, with a limit of 20 visits per year. Mental health specialty services, individual and group sessions for psychiatric services, and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams, additional preventive services, kidney disease education services, and other preventive services with no copay. Additional preventive services include coverage for therapeutic massage with a $5 copay. Several additional services such as in-home safety assessments, medical nutrition therapy, and counseling services are not covered.
Hearing Services See details
Hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, are covered. Prescription hearing aids are covered with a maximum plan benefit coverage of $3,000 every year, a copay between $200-$400, and a limit of 2 visits per year.
Vision Services See details
The SCAN Prime (HMO) plan covers vision services, including routine eye exams with no copay, and eyewear with a combined maximum plan benefit of $350 every year. This plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames; however, upgrades are not covered.
Dental Services See details
The SCAN Prime (HMO) plan covers various dental services, including oral exams and dental x-rays limited to two visits per year, other diagnostic dental services with a copay of $0-$5, and other preventive dental services with a copay of $0-$80. Restorative services have a copay of $8-$395, Adjunctive general services have a copay of $0-$125, Endodontics have a copay of $5-$395, Periodontics have a copay of $0-$380, Prosthodontics (removable) have a copay of $13-$395, Prosthodontics (fixed) have a copay of $25-$395, and Oral and Maxillofacial Surgery has a copay of $0-$140. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the SCAN Prime (HMO) plan, with a copay between $25.00 and $25.00. Prior authorization and a doctor referral are required.
Medical Equipment See details
Medical Equipment is covered by the SCAN Prime (HMO) plan. Durable Medical Equipment (DME) and Prosthetics/Medical Supplies have no copay or coinsurance, but services for Durable Medical Equipment for use outside the home, Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by SCAN Prime (HMO). Diagnostic Procedures/Tests, Lab Services, and Diagnostic Radiological Services are not covered. Therapeutic Radiological Services have a copay of at most $50, while Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by SCAN Prime (HMO) with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. A doctor's referral and prior authorization are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor referral, but additional days beyond Medicare coverage and non-Medicare-covered stays are not covered. The plan does not provide SNF services as a supplemental benefit under Part C.
Other Services See details
The SCAN Prime (HMO) plan covers acupuncture with a limit of 20 treatments per year, and over-the-counter (OTC) items with a maximum benefit of $150 every three months, and meal benefits. The plan does not cover the following services: Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.
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