MAPD 2027 plan HMO 3

SCAN Balance (HMO C-SNP)

Plan information effective January 1, 2027.

SCAN Health Plan Plan ID H5425-104-000 Plan #104 MAPD

Plan costs & ratings

Monthly premium$0.00

Annual premium$0.00

Medical premium$0.00

Medical deductible$0

Drug premium$0.00

Drug deductible$370

Medical out-of-pocket limit (in network)$399

Part D annual out-of-pocket threshold$2,400

Availability

Available in 2 California counties

Riverside County, CA, San Bernardino County, CA

Available Cities

This plan is available in 76+ cities in California.

Benefits

Primary care In Network

In-Network: $0 copay per visit

Inpatient hospital In Network

In-Network: $0 copay per admission.

Skilled nursing In Network

In-Network: $0 copay per day for days 1-20, $221 copay per day for days 21-100.

Emergency care In Network

In-Network: $115 copay per visit

Urgently needed care In Network

In-Network: $0 copay for Medicare-covered urgently-needed-care visits.

Ambulance In Network

In-Network: $200 copay per trip

Dental In Network

In-Network: $0 copay for Medicare-covered Dental Services

Vision In Network

This plan includes: Eye Exams, Eyewear.

Hearing In Network

In-Network: $0 copay for Medicare-covered Hearing Services

Over-the-counter In Network

In-Network: $0 copay; Maximum plan benefit coverage of $50.00 every month.

Transportation In Network

In-Network: $0 copay; Limit of 36 visits every year.

Fitness In Network

In-Network: $0 copay for Fitness Benefit.

Notes

Drug deductible details: $0 Deductible on Tier(s) 1, 2; $370 Deductible on Tier(s) 3, 4, 5

Plan Overview

CarrierSCAN Health Plan

OrganizationSCAN HEALTH PLAN

Plan typeMAPD

PlanHMO

SNP type3

Drug coverageIncluded

Enrollment hours8 am to 8 pm

Provider searchOpen provider directory

Carrier websiteOpen website

Plan identifiers

Plan IDH5425-104-000

Plan number104

ContractH5425

Segment0

DRX ID1TT7LYSDTJ

Carrier ID15

Formulary ID27384

Formulary versionV11 Last Updated 09-01-2026

Carrier contact

Carrier phone8778704867

Enrollment phone8778704867

Enrollment TTY711

Carrier hours8 am to 8 pm

Network & documents

Preferred pharmacy networkYes

Preferred retail pharmacyYes

Preferred mail pharmacyYes

Mail drug benefitsYes

Chronic Care