MAPD
2027 plan HMO
Sutter Senior Advantage, a SCAN Medicare Plan (HMO)
Plan information effective January 1, 2027.
SCAN Health Plan Plan ID H5425-126-000 Plan #126 MAPD
Plan costs & ratings
Monthly premium$19.00
Annual premium$228.00
Medical premium$19.00
Medical deductible$0
Drug premium$0.00
Drug deductible$250
Medical out-of-pocket limit (in network)$4,000
Part D annual out-of-pocket threshold$2,400
Availability
Available in 3 California counties
Placer County, CA, Sacramento County, CA, Yolo County, CA
Available Cities
This plan is available in 25+ cities in California.
Benefits
Primary care
In Network
In-Network: $5 copay per visit
Inpatient hospital
In Network
In-Network: $225 copay per day for days 1-6, $0 copay per day for days 7-90.
Skilled nursing
In Network
In-Network: $15 copay per day for days 1-100.
Emergency care
In Network
In-Network: $150 copay per visit
Urgently needed care
In Network
In-Network: $0 copay for Medicare-covered urgently-needed-care visits.
Ambulance
In Network
In-Network: $250 copay per trip
Dental
In Network
In-Network: $0 copay
Vision
In Network
This plan includes: Eye Exams, Eyewear.
Hearing
In Network
In-Network: $0 copay per visit; Limit of 1 visit every year.
Over-the-counter
In Network
In-Network: $0 copay; Maximum plan benefit coverage of $25.00 every 3 month.
Transportation
In Network
In-Network: $250 copay
Fitness
In Network
In-Network: $0 copay for Fitness Benefit.
Notes
Drug deductible details: $0 Deductible on Tier(s) 1, 2; $250 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 IDH5425-126-000
Plan number126
ContractH5425
Segment0
DRX ID1N1VL5Y4VC
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
