MAPD
2027 plan HMO
SCAN Costco Medicare Advantage (HMO)
Plan information effective January 1, 2027.
SCAN Health Plan Plan ID H5425-136-000 Plan #136 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$450
Medical out-of-pocket limit (in network)$699
Part D annual out-of-pocket threshold$2,400
Availability
Available in 2 California counties
Fresno County, CA, Kings County, CA
Available Cities
This plan is available in 10+ cities in California.
Benefits
Primary care
In Network
In-Network: $0 copay per visit
Inpatient hospital
In Network
In-Network: $0 copay per day for days 1-2, $50 copay per day for days 3-7, $0 copay per day for days 8-90.
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: $90 copay per visit
Urgently needed care
In Network
In-Network: $0 copay for Medicare-covered urgently-needed-care visits.
Ambulance
In Network
In-Network: $75 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 $125.00 every 3 month.
Transportation
In Network
In-Network: $0 copay; Limit of 12 visits every year.
Fitness
In Network
In-Network: $0 copay for Fitness Benefit.
Notes
Drug deductible details: $0 Deductible on Tier(s) 1, 2; $450 Deductible on Tier(s) 3, 4, 5
Plan Overview
CarrierSCAN Health Plan
OrganizationSCAN HEALTH PLAN
Plan typeMAPD
PlanHMO
Drug coverageIncluded
Enrollment hours8 am to 8 pm
Plan identifiers
Plan IDH5425-136-000
Plan number136
ContractH5425
Segment0
DRX ID18892MJCSQ
Carrier ID15
Formulary ID27384
Formulary versionV11 Last Updated 09-01-2026
Carrier contact
Carrier phone8336089576
Enrollment phone8336089576
Enrollment TTY711
Carrier hours8 am to 8 pm
Network & documents
Preferred pharmacy networkYes
Preferred retail pharmacyYes
Preferred mail pharmacyYes
Mail drug benefitsYes
