![]() Prior authorization rules apply for specialist visits. Prior authorization rules apply for outpatient hospital services. Inpatient Hospital Coverage Outpatient Hospital Services Ambulatory Surgical Center Outpatient Hospital Doctor Visits Primary Care Specialists $150 copay per day for days 1-6 per day for days 7-90 and beyond $5-$275 copay per visit -$5 copay per visit Our plan covers an unlimited number of days for an inpatient hospital stay. ![]() Maximum Out of Pocket Responsibility (this does not include prescription drugs) $1,800 annually The most you pay for copays and coinsurance for Medicare-covered medical services for the year. Part B Premium Give Back $50 per month Deductible This plan does not have a deductible. To get a complete list of services we cover, please request the Evidence of Coverage by calling our Member Services Department at the phone number listed in this document or online at Y0057_SCAN_20047_2023_M 08/22 23C-NVSMB7000ģ SUMMARY OF BENEFITS JANUDECEMPREMIUM AND BENEFITS SCAN VENTURE WHAT YOU SHOULD KNOW Monthly Health Plan Premium per month You must continue to pay your Medicare Part B premium. The benefit information provided does not list every service that we cover or list every limitation or exclusion. You must continue to pay your Medicare Part B premium. Enrollment in SCAN Health Plan depends on contract renewal. 1 2023 SUMMARY OF BENEFITS SCAN Venture (HMO) Clark County JanuDecemSCAN Venture (HMO) is an HMO plan with a Medicare contract.
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