SCAN Classic WA (HMO)
Available to residents of Pierce County, WA for 2027. Contract H4026, plan 001, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Pierce County
- Plan website
- Browse the SCAN Classic WA (HMO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Consolidated into another plan for 2027. CMS carries this plan forward from 2026. Every WA plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $1.00 |
|---|---|
| — medical (Part C) part | $1.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $1.00?drug (Part D) part $0.00; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $7,150.00? |
| Drug deductible | $550.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO? |
| Contract / plan | H4026-001-0 |
| Offered by | SCAN Health Plan |
| Parent organization | SCAN Group |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.scanhealthplan.com |
| Member services | (833)945-7226TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H4026 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $55 copay(authorization and referral required) |
| Other health care professional | $0–$55 copay(authorization and referral required) |
| Additional telehealth services | $0–$55 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 | $10 copay(authorization and referral required) |
| Lab services | $0 copay(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$350 copay(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | $30 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $50 copay |
| Worldwide emergency coverage | $130 copay |
| Worldwide urgent care | $50 copay |
| Worldwide emergency transportation | $250 copay |
| Hospital care | |
| Inpatient hospital stay | $550 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient hospital services | $0–$550 copay(authorization and referral required) |
| Outpatient observation | $550 copay(authorization and referral required) |
| Ambulatory surgical center | $0–$500 copay(authorization and referral required) |
| Outpatient blood services | $0 copay(authorization and referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $10 per day for days 1–20; $100 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 | $50 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $55 copay(authorization and referral required) |
| Cardiac rehabilitation | $40 copay(authorization and referral required) |
| Pulmonary rehabilitation | $35 copay(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $550 per day for days 1–4; $0 per day for days 5–90(authorization and referral required) |
| Outpatient mental health, individual session | $55 copay(authorization and referral required) |
| Outpatient mental health, group session | $55 copay(authorization and referral required) |
| Psychiatrist, individual session | $55 copay(authorization and referral required) |
| Psychiatrist, group session | $55 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 | $55 copay(authorization and referral required) |
| Outpatient substance use, group session | $55 copay(authorization and referral required) |
| Opioid treatment program | $55 copay(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | $250 copay(authorization required) |
| Air ambulance | $250 copay(authorization required) |
| Transportation to plan-approved locations | Not covered |
| 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%–20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(authorization and referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $55 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $55 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 | $0 copay(limits apply) |
| Other preventive dental services | $0 copay(limits apply) |
| Comprehensive dental plan limit | $1,500 plan limit every year |
| Restorative services (fillings, crowns) | 25% coinsurance |
| Endodontics (root canals) | 25% coinsurance |
| Periodontics (gum disease) | 25% coinsurance |
| Dentures and other removable prosthodontics | 25% coinsurance |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | 25% coinsurance |
| Oral and maxillofacial surgery | 25% coinsurance |
| Orthodontics | Not covered |
| Adjunctive general services | 25% coinsurance |
| Vision? | |
| Eye exam (Medicare-covered) | $0–$55 copay(authorization and referral required) |
| Routine eye exam | $0 copay(authorization and referral required, limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $55 copay(authorization and referral required, limits apply) |
| Eyewear plan limit | $175 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) | $45 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–$950 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 | Not covered |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| 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 |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| 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 | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). 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 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $0.00 |
| Tier 3 · Preferred Brand | $42.00 |
| Tier 4 · Non-Preferred Drug | 35% |
| Tier 5 · Specialty Tier | 27% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial 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 | $42.00 | $42.00 | $42.00 | $126.00 | $126.00 | $126.00 |
| Tier 4: Non-Preferred Drug | 35% | 35% | 35% | 35% | 35% | 35% |
| Tier 5: Specialty Tier | 27% | 27% | 27% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | too new |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | too new |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H4026 shares it.
Also available in 2 other WA counties
Benefits in plain text
SCAN Classic WA (HMO) (H4026-001-0) is a 2027 HMO Medicare Advantage plan offered by SCAN Health Plan, available to residents of Pierce County, WA.
The monthly premium is $1.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $1.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $7,150.00.
The drug deductible is $550.00. Tier 1 and 2 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $0.00; tier 3 (Preferred Brand): $42.00; tier 4 (Non-Preferred Drug): 35%; tier 5 (Specialty Tier): 27%.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.