SCAN Classic (HMO)
Available to residents of Yolo County, CA for 2026. Contract H5425, plan 128, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Yolo County
- Plan website
- Browse the SCAN Classic (HMO) formulary
New for 2026. This plan has no 2025 predecessor in the CMS crosswalk.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $2,000.00? |
| Drug deductible | $250.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H5425-128-0 |
| Offered by | SCAN Health Plan |
| Parent organization | SCAN Group |
| Formulary drugs | 3,604 |
| Formulary exception tier | 4? |
| Pharmacy search | www.scanhealthplan.com |
| Member services | (888)315-7226TTY 711 |
CMS star ratings
- Overall
- 4 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5425 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0 copay(authorization and referral required) |
| Other health care professional | $0 copay(authorization and referral required) |
| Additional telehealth services | $0 copay(authorization and referral required) |
| Preventive care | |
| Medicare-covered preventive services | $0 copay(authorization and referral required) |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay(authorization and referral required) |
| Glaucoma screening | $0 copay(authorization and referral required) |
| Diabetes self-management training | $0 copay(authorization and referral required) |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0 copay(authorization and referral required) |
| Lab services | $0 copay(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$50 copay(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | $0 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $90 copay |
| Urgent care | $0 copay |
| Worldwide emergency coverage | $90 copay |
| Worldwide urgent care | $0 copay |
| Worldwide emergency transportation | $150 copay |
| Hospital care | |
| Inpatient hospital stay | $50 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient hospital services | $75 copay(authorization and referral required) |
| Outpatient observation | $0 copay(authorization and referral required) |
| Ambulatory surgical center | $75 copay(authorization and referral required) |
| Outpatient blood services | $0 copay(authorization and referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $50 per day for days 21–100(authorization and referral required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance(authorization and referral required) |
| Rehabilitation | |
| Occupational therapy | $5 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $5 copay(authorization and referral required) |
| Cardiac rehabilitation | $5 copay(authorization and referral required) |
| Pulmonary rehabilitation | $5 copay(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $50 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient mental health, individual session | $5 copay(authorization and referral required) |
| Outpatient mental health, group session | $5 copay(authorization and referral required) |
| Psychiatrist, individual session | $5 copay(authorization and referral required) |
| Psychiatrist, group session | $5 copay(authorization and referral required) |
| Partial hospitalization | $55 copay(authorization and referral required) |
| Intensive outpatient program | $55 copay(authorization required) |
| Outpatient substance use, individual session | $5 copay(authorization and referral required) |
| Outpatient substance use, group session | $5 copay(authorization and referral required) |
| Opioid treatment program | $5 copay(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | $150 copay(authorization required) |
| Air ambulance | $150 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance(authorization required) |
| Medical supplies | 0%–20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $0 copay(authorization and referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $5 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $0 copay(authorization required) |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Comprehensive dental plan limit | $3,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay(authorization required) |
| Endodontics (root canals) | $0 copay(authorization required) |
| Periodontics (gum disease) | $0 copay(authorization required) |
| Dentures and other removable prosthodontics | $0 copay(authorization required) |
| Maxillofacial prosthetics | $0 copay(authorization required) |
| Implants | $0 copay(authorization required) |
| Bridges and other fixed prosthodontics | $0 copay(authorization required) |
| Oral and maxillofacial surgery | $0 copay(authorization required) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required) |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay(authorization and referral required) |
| Routine eye exam | $0 copay(authorization and referral required, limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(authorization and referral required, limits apply) |
| Eyewear plan limit | $250 plan limit every year |
| Contact lenses | $0 copay(authorization and referral required, limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(authorization and referral required, limits apply) |
| Eyeglass lenses | $0 copay(authorization and referral required, limits apply) |
| Eyeglass frames | $0 copay(authorization and referral required, limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay(authorization and referral required) |
| Routine hearing exam | $0 copay(authorization and referral required, limits apply) |
| Hearing aid fitting and evaluation | $0 copay(authorization and referral required) |
| Hearing aids (all types) | $550–$850 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $110 allowance every three months |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization required) |
| Fitness benefit | $0 copay(authorization required) |
| Health education | $0 copay(authorization required) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(authorization required) |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | $0 copay(authorization required) |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | $0 copay(authorization required) |
| Support for caregivers | $0 copay(authorization required) |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | $42.00 |
| Tier 4 | 35% |
| Tier 5 | 30% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $10.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | $0.00 | $0.00 | $20.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $10.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | $0.00 | $0.00 | $20.00 | $0.00 |
| Tier 3: Preferred Brand | $42.00 | $47.00 | $42.00 | $126.00 | $141.00 | $126.00 |
| Tier 4: Non-Preferred Drug | 35% | 35% | 35% | 35% | 35% | 35% |
| Tier 5: Specialty Tier | 30% | 30% | 30% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 3 other CA counties
Benefits in plain text
SCAN Classic (HMO) (H5425-128-0) is a 2026 HMO Medicare Advantage plan offered by SCAN Health Plan, available to residents of Yolo County, CA.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $2,000.00.
The drug deductible is $250.00. Tier 1 and 2 exempt.
The plan's formulary lists 3,604 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: $42.00; tier 4: 35%; tier 5: 30%.
CMS gives the plan's contract (H5425) an overall rating of 4 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.