SCAN Compass (HMO)
H5425 - 115 - 0
(3.5 / 5)
SCAN Compass (HMO) is a Medicare Advantage Plan by SCAN Health Plan.
This page features plan details for 2024 SCAN Compass (HMO) H5425 – 115 – 0.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
SCAN Compass (HMO) is offered in the following locations.
Plan Overview
SCAN Compass (HMO) offers the following coverage and cost-sharing.
| Insurer: | SCAN Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $1,000 In-network |
| Drugs Covered: | Yes |
Ready to sign up for SCAN Compass (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
SCAN Compass (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
SCAN Compass (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 | $7.00 copay | $0.00 copay | $7.00 copay |
| 2 (Generic) | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
| 3 (Preferred Brand) | $35.00 copay | $47.00 copay | $35.00 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 | $14.00 copay | $0.00 copay | $14.00 copay |
| 2 (Generic) | $0.00 copay | $30.00 copay | $0.00 copay | $30.00 copay |
| 3 (Preferred Brand) | $85.00 copay | $121.00 copay | $85.00 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 | $7.00 copay | $0.00 copay | $7.00 copay |
| 2 (Generic) | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $14.00 copay | $0.00 copay | $14.00 copay |
| 2 (Generic) | $0.00 copay | $30.00 copay | $0.00 copay | $30.00 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
SCAN Compass (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $1,000 In-network |
| Yes |
| In-network | No |
| $0 copay (Authorization is required.) (Referral is required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $10 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 | $0 copay (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) | $0-110 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 | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0-125 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | $0-5 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $8-395 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $5-395 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0-380 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0-140 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $13-395 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not 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 | $10 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| $100 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $10 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) | $0 copay (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | $0 copay (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.) |
| $0 copay (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $0 copay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $15 copay (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is required.) (Referral is required.) |
| Monthly Premium | $42.00 |
| Deductible | nan |
Ready to sign up for SCAN Compass (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