2017 Benefit Highlights

Los Angeles and Orange Counties
2017 Benefit Highlights
VillageHealth (HMO−POS SNP)
VillageHealth
Plan Details
(Medicare & Full
Medi-Cal Eligibility)
In & Out-of-Network
(With Medicare
Only)
In-Network
(With Medicare
Only)
Out-of-Network
Monthly Plan Premium
$0
$36.30*
$36.30*
Annual Plan Deductible
$0
Medicare fee-forservice deductible
Medicare fee-forservice deductible
Comprehensive Care
(Medicare & Full
Medi-Cal Eligibility)
In & Out-of-Network
(With Medicare
Only) In-Network
(With Medicare
Only)
Out-of-Network
Primary Care Office Visits
$0
$0
20%
Specialist Office Visits
$0
$0-20%
20%
Diabetes Monitoring Supplies
$0
$0
$0
Diagnostic Tests and Procedures
$0
20%
20%
Lab services
$0
$0
$0
X-Rays
$0
$0
20%
Diagnostic Radiology
$0
$0
20%
Therapeutic Radiology
$0
20%
20%
Durable Medical Equipment
$0
20%
Not Covered
Outpatient Mental Health (Indiv/Grp)
$0
$0
20%
Outpatient Rehabilitation
$0
20%
20%
Annual Physical Exam
$0
$0
Not Covered
Preventive Services
$0
$0
$0
Hospital
and Emergency Care
(Medicare & Full
Medi-Cal Eligibility)
In & Out-of-Network
(With Medicare
Only)
In-Network
(With Medicare Only)
Out-of-Network
Inpatient Hospital Care
$0
Skilled Nursing Facility
$0
Outpatient Surgery
Medicare fee-forservices deductible
Medicare fee-forservices deductible
Medicare fee-forservices deductible
$0
20%
20%
Emergency Care
$0 (U.S. only)
20% (U.S. only)
($0 if immediately
admitted)
20% (U.S. only)
($0 if immediately
admitted)
Urgent Care Services
$0 (U.S. only)
$0 (U.S. only)
20% (U.S. only)
Ambulance Services
$0
(per one-way trip)
20%
(per one-way trip)
20%
(per one-way trip)
Maximum Out-of-Pocket
(Medicare & Full
Medi-Cal Eligibility)
In & Out-of-Network
(With Medicare
Only)
In-Network
(With Medicare Only)
Out-of-Network
Annual Maximum Out-of-Pocket (MOOP)
$6,700
$6,700
$6,700
Not Covered
Prescription Drug
Coverage
Pharmacy Network
(Medicare & Full Medi-Cal
Eligibility)
(With Medicare Only)*
Preferred
Standard
Preferred
Standard
$0
$0
$400
$400
Part D Deductible
Initial Coverage Stage - SCAN Contracted Pharmacy (1-month/30-day Supply of Drugs)
TIER 1: Preferred Generic Drugs
$0
TIER 2: Generic Drugs
$0 or $1.20
or $3.30
$0
$3.50
$0 or $1.20 or $3.30
25%
TIER 3: Preferred Brand Drugs
$0 or $1.20 or $3.30 or
$3.70 or $8.25
25%
TIER 4: Non-Preferred Drugs
$0 or $1.20 or $3.30 or
$3.70 or $8.25
25%
TIER 5: Specialty Tier Drugs
$0 or $1.20 or $3.30 or
$3.70 or $8.25
25%
$0 or $3.70 or $8.25
$11
TIER 6: Select Care Drugs
* If you qualify for “Extra Help” with your prescription drug costs, the “Extra Help” program will pay all or part of your
monthly plan premium and your prescription drug deductibles and copays/coinsurance.
Additional Benefits
and Services
(Medicare & Full Medi-Cal
Eligibility)
In-Network
(With Medicare Only)
In-Network Only
Access to a personal
VillageHealth nurse
$0
$0
Access to a VillageHealth pharmacist
to assist with medication questions
$0
$0
Dental Exams
$0 (1 per year)
$0 (1 per year)
Dental Cleaning
Dental X-Rays
$0 (2 visits per year)
$0 (every 6 months)
$0 (2 visits per year)
$0 (every 6 months)
$0 (1 per year)
$0 (1 per year)
$0 (every 2 years)
$0 (every 2 years)
$175 (every 2 years)
$175 (every 2 years)
$0 (every 6 visits)
$0 (unlimited)
$0
$0 (every 6 visits)
$0 (unlimited)
$0
$0 (criteria and limitations
apply)
$0 (criteria and limitations
apply)
Dental Services (Routine)
Vision Services (Routine)
Eye Exam
Glasses or Contacts Copay
C
overage for Frame or Contact
Lenses
Podiatry Services (Routine)
Transportation (Routine)
Health Club Membership
Home Delivered Meals
CALL
To contact an authorized
VillageHealth representative today
For more information, call the number below
1- 877- 916-1234
8 a.m. to 8 p.m., Monday through Friday, Pacific Time
8 a.m. to 8 p.m., 7 days a week, Pacific Time
(From October 1 through February 14)
TTY users: 711
Or visit our website
www.villagehealthca.com
VillageHealth is an HMO Plan with a Medicare contract. Enrollment in VillageHealth depends on contract renewal. You must
continue to pay your Medicare Part B premium. VillageHealth is available to ESRD dialysis patients, pre-kidney transplant and
post-kidney transplant patients.
This information is not a complete description of benefits. Contact the plan for more information. Benefits, premium,
co-payments and/or co-insurance may change on January 1 of each year. Limitations, copayments and restrictions may apply.
The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
Calling the agent number will direct you to a licensed insurance agent.
SCAN Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. SCAN Health Plan cumple con las leyes federales de derechos civiles aplicables y no
discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. SCAN Health Plan 遵守適用的聯邦民權法律
規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視 任何人。 ATTENTION: If you speak a language other than
English, language assistance services, free of charge, are available to you. Call 1-800-399-7226. Hours are 8 a.m. to
8 p.m., seven days a week from October 1 to February 14. From February 15 to September 30 hours are 8 a.m. to 8 p.m.
Monday through Friday. Messages received on holidays and outside of our business hours will be returned within one
business day. (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-399-7226. El horario es de 8 a. m. a 8 p. m., los siete días de la semana, del 1 de octubre al 14 de
febrero. Del 15 de febrero al 30 de septiembre, nuestro horario es de 8 a. m. a 8 p. m., de lunes a viernes. Los mensajes
recibidos en días festivos o fuera de nuestras horas de oficina serán contestados dentro de un día hábil. (TTY: 711). 注意：
如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-399-7226。10 月 1 日至 2 月 14 日期間的服務時間為早
上 8 點至晚上 8 點，每週七天。2 月 15 日至 9 月 30 日期間的服務時間為週一至週五，早上 8 點至晚上 8 點。在節假日及營業
時間之外收到的訊息將在一個工作日內回覆。
（聽障專線：711）。
Y0057_SCAN_9705_2016F File & Use Accepted 08142016
G9931 10/16 17C-BHLVH2