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SCAN
877-888-9612
www.scanhealthplan.com
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SECURE
HORIZONS
800-228-2144
www.securehorizons.com
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UHP
Healthcare
for Seniors
800-847-1222
www.uhphealthcare.com
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COUNTIES COVERED
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RIVERSIDE
SAN BERNARDIN0
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RIVERSIDE
SAN BERNARDINO
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SAN BERNARDINO ONLY!
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MONTHLY PREMIUM
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$40
(plus $54 for
Medicare Part B)
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$30
(plus $54 for
Medicare Part B)
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$0
(plus $54 for Medicare Part B)
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OFFICE VISIT
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$5
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$10
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$5
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HOSPITALIZATION
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$0 for inpatient hospital
services. Covered for
unlimited days each benefit period.
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$275 for each Medicare covered stay.
Covered for unlimited days each benefit period.
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$0 for inpatient hospital services.
Covered for unlimited days each benefit period.
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PRESCRIPTION
DRUGS
Co-Payment and Cap
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Formulary/Non Form.
generic $7/30 day sup. Form. Pref. Brand $25/30 day sup. Form. Brand
$25/30 day sup. Non-Form.
Brand $40/30 day sup. Mail: Form.Gen. $14/90 day sup. Form. Pref. Brand $50/90 day sup.
Non Form. Brand $120/90 day sup. NO LIMIT.
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Formulary generic
$9/30 day sup.
Mail Order: Formulary generic $18/90 day supply.
NO LIMIT on Formulary
Generic Drugs
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Formulary Generic
$10/30 day supply. Form. Brand $20/30 day supply.
Mail order: Formulary Generic $20/90 day supply. Formulary Brand $40/90 day supply. Limit:
$200 month for combined Form. Generic & Form. Brand
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SKILLED NURSING
Facility Co-Payment
(Medicare Criteria
applies)
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$0 up to 100 days
per benefit period. No
prior hospital stay is required.
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$0 for 1-20 days.
$50 per day for days 21-100. No hospital stay is required.
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$0 up to 150 days.
3 day prior hospital stay required
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AMBULANCE
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$0 for ambulance services
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$50 for Medicare-covered
ambulance services
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$0 for Medicare-covered
ambulance services.
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CHIROPRACTIC
CARE
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$5 for each Medicare
covered visit.
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$10 for each Medicare
covered visit.
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$5 for each Medicare
covered visit.
$15 for each routine
visit up to 12 visits per year.
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DENTAL CARE
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$8 for office visit
includes: oral exams, cleanings, x-rays
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NOT COVERED.
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$25 for each cleaning
up to 2 visits each year.
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EMERGENCY ROOM
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$25 for each Medicare-covered
ER visit, waived if admitted to hospital. Worldwide Coverage
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$50 for each Medicare-covered
ER visit. Worldwide
coverage.
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$25 for each Medicare
covered ER visit. Not covered outside U.S., except special
circumstances.
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HEARING CARE
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$5 each Medicare-covered
hearing exam(diagnostic hearing exams). $5 per routine hearing test. Up to $300 for
hearing aids every 2 yrs.
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$10 for each Medicare-covered
hearing exam (diagnostic hearing exams). Hearing aids not covered.
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$5 for each Medicare-covered
hearing exam (diagnostic hearing exams) $5 for routine hearing test 1 per yr. Hearing aids not covered.
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HOME HEALTH CARE
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$0 for Medicare- covered
home health visits.
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$0 for Medicare-covered
home health visits.
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$0 for Medicare-covered
home health visits.
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MENTAL HEALTH CARE
(Outpatient)
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$10 for Medicare-covered
mental health services.
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$10 for Medicare-covered
mental health services
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$5 for Medicare-covered
mental health services.
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PODIATRY CARE
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$5 for each Medicare-covered
visit (medically necessary foot care). $5 for each routine visit.
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$10 for each Medicare-covered
visit (medically necessary foot care).
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$5 for each Medicare-covered
visit (medically necessary foot care). $5 for each routine visit.
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VISION CARE
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$5 for each Medicare-covered
eye exam; $5 for each routine eye exam 1 exam a yr. Up to $55 in eye wear per yr.
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$10 for Medicare-covered
eye exam(diagnosis/ treatment). $10 for each routine exam. Up
to $75 for eye wear every two years.
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$5 for Medicare-covered
eye exam (diagnosis/treatment). $5 for routine eye exam, 1 per
year. $25 for frames
every 2 years.
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URGENT CARE
OUT OF SERVICE AREA
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$25 for each Medicare-covered
urgently needed care visit.
Waived if admitted to hospital within 24 hrs.
Worldwide coverage.
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$10-50 for each Medicare-covered
urgently needed care visit. Waived if admitted to hospital within
24 hrs. Worldwide coverage.
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$5 for each Medicare-covered
urgently needed care visit.
Not covered outside of U.S. except special circumstances.
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PREVENTIVE SERVICES*
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$5 annual routine
physical
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$10 annual routine
physical
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$5 routine physical
exam – 1 per year.
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