Better Medicare
Starts Here.
SCAN Health Plan
2026 Benefit highlights Bexar
Fort Bend
SCAN Classic Texas (HMO) Harris
SCAN Balance Texas (HMO C-SNP) Montgomery
Plan Details SCAN Classic Texas SCAN Balance Texas
Monthly Plan Premium $0 $0
Annual Plan Deductible $0 $0
Maximum Out-of-Pocket SCAN Classic Texas SCAN Balance Texas
Annual Maximum Out-of-Pocket
$2,900 $2,000
(MOOP)
Comprehensive Care SCAN Classic Texas SCAN Balance Texas
Primary Care Office Visits $0 $0
Specialist Office Visits $15 $0-$15
Diabetic Self-Management
$0 $0
Training
Diabetic Supplies
$0 $0
(lancets, test strips, monitor)
Continuous Glucose Monitors
$0 at the pharmacy or DME $0 at the pharmacy or DME
(available through DME or at
provider provider
your Pharmacy)
$0 for items up to $499; $0 for items up to $499;
Durable Medical Equipment
20% for items $500 and more 20% for items $500 and more
Annual Physical Exam $0 $0
Preventive Services
$0 $0
(Medicare-covered screenings)
Lab Services and X-rays $0 $0
Diagnostic Tests and
$30 $30
Procedures
Outpatient Rehabilitation
$15 $15
(e.g. PT, OT, ST)
Diagnostic Radiology
$0-$125 $0-$125
(e.g. MRI, CT, ultrasound)
Outpatient Mental Health
$15 $15
(Individual/Group)
Hospital and Emergency Care SCAN Classic Texas SCAN Balance Texas
$95 per day (1-5) $95 per day (1-5)
Inpatient Hospital Care
$0 per day (6-90+) $0 per day (6-90+)
$0 per day (1-20) $0 per day (1-20)
Skilled Nursing Facility
$140 per day (21-100) $140 per day (21-100)
Outpatient Surgery $15-$150 $15-$150
$90 (worldwide) $90 (worldwide)
Emergency Care
$0 (if admitted immediately) $0 (if admitted immediately)
Urgent Care Services $20 (worldwide) $20 (worldwide)
Ambulance Services $225 $225
Prescription Drug Coverage SCAN Classic Texas SCAN Balance Texas
Part D Deductible $0 $0
Initial Coverage Stage - SCAN Contracted Retail Pharmacies (1-month/30-day supply)
Pharmacy Network PREFERRED STANDARD PREFERRED STANDARD
Tier 1: Preferred Generic $0 $0 $0 $0
Tier 2: Generic $0 $7 $0 $7
Tier 3: Insulin $35 $35 $0 $0
Preferred Brand Other Drugs $42 $47 $42 $47
Tier 4: Non-Preferred Drug 35% 35% 35% 35%
Tier 5: Specialty Tier 33% 33% 33% 33%
Part D Out-of-Pocket Maximum $2,100 $2,100
Catastrophic Coverage Stage $0 $0
$0 Prescription Drugs
$0 on Tier 1 and Tier 2 drugs are available at SCAN preferred pharmacies.
Dental Services SCAN Classic and SCAN Balance
$3,500 Allowance for In-network and Out-of-network services
Dental coverage to support
0% cost share for In-network services up to allowance amount
your overall health.
50% cost share for Out-of-network services up to allowance amount
DIAGNOSTIC AND PREVENTIVE DENTAL*
Oral Exams (2 per year) $0
Dental X-rays (1 per year) $0
Prophylaxis (cleaning - 2 per year) $0
Flouride Treatment (2 per year) $0
COMPREHENSIVE DENTAL
Restorative Services (fillings, crowns) $0
Endodontics (root canals) $0
Periodontics (deep cleaning) $0
Prosthodontics (dentures, bridges) $0
Maxillofacial Prosthetics (facial/jaw prosthetics post surgery/trauma) $0
Implant Services (dental implant placement and restoration) $0
Oral and Maxillofacial Surgery (tooth extractions, jaw surgery) $0
*Diagnostic and Preventive dental services do not count towards allowance
SCAN Covers These Valuable Extras
Extras that help you stay healthy and independent
Benefits SCAN Classic Texas SCAN Balance Texas
Vision (routine)
Eye exam $0 (1 every 12 months) $0 (1 every 12 months)
Coverage for eyewear $300 limit allowance every year $325 limit allowance every year
Hearing $550-$850 per aid/year $550-$850 per aid/year
Transportation* $0 (54 one-way trips per year) $0 (54 one-way trips per year)
Non-medical*** Not available 28 of the 54 trips
FlexEssentials Card
Over-the-counter products $100 per quarter with rollover can $55 per month with no rollover
(OTC) be used on OTC products (mail can be used for eligible OTC and
order or CVS retail stores) grocery items (select retailers)
Groceries*** Not covered
Fitness $0 (One Pass) $0 (One Pass)
Acupuncture and $5 per visit (20 visits/year $5 per visit (20 visits/year
Chiropractic Services combined) combined)
(routine)
Extras that connect you to even more care and support
Benefits SCAN Classic Texas SCAN Balance Texas
At-Home Support** After hospitalization, after a hip or After hospitalization, after a hip or
knee replacement, or assistance knee replacement, or assistance
with two or more activities of daily with two or more activities of daily
living. living.
Respite Up to 20 hours per year Up to 40 hours per year
In-Home Care Visits $0 for personal in-home care visits, $0 for personal in-home care visits,
up to 80 hours over 20 visits per up to 100 hours over 25 visits per
year year
Meals (post-hospitalization) $0 for home-delivered meals, up to $0 for home-delivered meals, up to
28 days or 84 meals 28 days or 84 meals
Meals (chronic conditions) $0 for home-delivered meals, up to $0 for home-delivered meals, up to
28 days or 84 meals 28 days or 84 meals
Care Memory Assistance $0 $0
Program (Care MAP) Comprehensive assessment, care Comprehensive assessment, care
planning, 24/7 support line and planning, 24/7 support line and
caregiver training for individuals caregiver training for individuals
with a diagnosis or at risk for with a diagnosis or at risk for
dementia. dementia.
*50-mile limit will apply to each one-way trip. **Criteria and limitations apply.
***This is a special supplemental benefit for chronically ill members. That means, to get this benefit, you must have an eligible
chronic condition such as heart disease, diabetes, cancer, lung disease, or dementia. Other chronic conditions may apply. Not all
members with chronic conditions may qualify. See your Evidence of Coverage for a complete list of eligible chronic conditions and
coverage criteria. For more information, please call Member Services.
Extras that connect you to even more care and support (con’t)
Benefits SCAN Classic Texas SCAN Balance Texas
Telehealth Urgent Medical $0 $0
Telehealth Behavioral Health $0 $0
Nurse Advice Line $0 (per phone visit) $0 (per phone visit)
Healthtech $0 support line $0 support line
Personal Emergency $0 (includes installation and $0 (includes installation and
Response System (PERS) monthly fees) monthly fees)
Worldwide Care Urgent or emergency care when Urgent or emergency care when
outside of the U.S. outside of the U.S.
Take a look at these plan highlights
$0 for the medications members use most
That’s right, $0 for drugs on Tier 1 and Tier 2 of our generous Formulary (list of covered
drugs). And, for SCAN Balance plan members, covered insulins are also $0.
Money for Over-the-Counter (OTC) items and groceries
Use the FlexEssentials card on OTC items and, for those who qualify, groceries.
Shop at stores like CVS, Safeway, Walmart—and many popular local markets!
A dental allowance to spend where and how you want
Preventive care doesn’t count toward your allowance, so you can spend it on the procedures
that matter most to you, including implants and dentures, with coverage in and out of network.
The in-home care you need, when you need it
Whether you’re just out of the hospital, had a knee or hip replaced, or need help with
daily activities, SCAN is here with care, support and even meals.
A Better Medicare Experience
SCAN was founded by seniors, for seniors in 1977.
Since then, we’ve become an award-winning
Medicare Advantage plan -with a difference.
We’re proudly nonprofit.
We don’t have shareholders we have to please.
Instead, we have members looking to us to
give them a better Medicare experience.
One that’s based on quality, senior-focused care and
award-winning service. That’s our commitment to you.
We look forward to showing you the SCAN difference.
[Link]
1‑855‑848‑7226 (TTY: 711)
SCAN Classic Texas (HMO) and SCAN Balance Texas (HMO C-SNP) are HMO plans with Medicare contracts. Enrollment in
SCAN Health Plan depends on contract renewal. You must continue to pay your Medicare Part B premium. Other providers
and pharmacies are available in SCAN Health Plan’s network.
Please refer to your Summary of Benefits for more details about all the benefits and services you get with your Medicare
Advantage Plan. If you have any questions, just call us. An authorized SCAN representative will be happy to help you.
You won’t pay more than $35 for a one‑month supply and no more than $105 for a three‑month supply of each insulin product
covered by our plan, no matter what cost‑sharing tier it’s on. Most adult Part D vaccines are covered by our plan at no cost to
you. For more information, please refer to your “Drug List” (Formulary). If you have questions about the Drug List, you can also
call Member Services. Prescription copay/coinsurance may vary by plan, county, pharmacy type (e.g., Preferred or Standard,
etc.), day supply, Part D benefit phase, or in members who receive “Extra Help.” You can fill your prescriptions at any of our
network pharmacies, but you may pay less at a Preferred pharmacy. Check your Evidence of Coverage or call Member Services
for details (phone numbers for Member Services are printed on the back cover of your Evidence of Coverage). Out‑of‑network/
non-contracted providers are under no obligation to treat plan members, except in emergency situations.
You can get prescription drugs shipped to your home through our network mail‑order delivery program. Express Scripts
PharmacySM is our Preferred mail‑order pharmacy. While you can fill your prescription medications at any of our network
mail‑order pharmacies, you may pay less at the Preferred mail‑order pharmacy. Typically, you should expect to receive your
prescription drugs within 14 days from the time that Express Scripts mail‑order pharmacy receives the order. If you do not
receive your prescription drug(s) within this time, please contact SCAN Health Plan’s Member Services. For your mail‑order
prescriptions, you have the option to sign up for an automatic refill program by contacting Express Scripts Pharmacy at
1‑866‑553‑4125, 24 hours a day, 7 days a week. TTY users call 711. You may opt out of automatic deliveries at any time.
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