ENROLLMENT HEALTH AND WELLNESS 25 Plan Feature Scripps HMO Option Scripps EPO Option Who Directs and Provides Care Scripps HMO Network Scripps Custom Network Employee Cost $ $$ Annual Deductible $0 $0 Annual Out-of-Pocket Maximum $1,500 per person; $3,000 per family $3,000 per person; $6,000 per family Physician Services Telehealth See a doctor online, 24/7 from your smartphone, tablet or computer (learn more page 32) Scripps Video Visits $25 copay PCP visit $40 copay specialist visit Doctor on Demand $25 copay for medical/therapy visit Scripps Video Visits $30 copay PCP visit $45 copay specialist visit LiveHealth Online $30 copay for medical/therapy visit Primary Care Physician Visit $25 copay $30 copay ($40 copay if no PCP designated) Specialist Visit $40 copay $45 copay Preventive Care Such as routine physicals, immunizations, well-child care, well-woman exams, mammograms $0 copay (age & frequency schedules apply) $0 copay (age & frequency schedules apply) Surgery & Hospitalization Outpatient Surgery $200 copay $250 copay Hospitalization • Inpatient Semi-Private Room • Inpatient Physician Scripps HMO Network Hospitals only $300 copay per admission $0 copay Scripps Custom Network Hospitals only $300 copay per admission $0 copay Urgent & Emergency Care Urgent Care $45 copay $55 copay Emergency Room $175 copay (waived if admitted) $200 copay (waived if admitted) Ambulance $150 copay $150 copay Other Services Diagnostic Lab/X-ray • Lab & X-ray • Outpatient Advanced Imaging* $0 copay $150 copay $0 copay $150 copay ($450 copay max/yr) Physical & Occupational Therapy** $30 copay $35 copay Chiropractic & Acupuncture Care Care provided by American Specialty Health $15 copay (20 combined visits per year) Care provided by Anthem Blue Cross $30 copay (20 combined visits per year) Allergy Serum • Testing • Injections/Serum $15 copay $10 copay/visit $25 copay $10 copay/visit Durable Medical Equipment 100% after $250 deductible 100% after $300 deductible Some family planning services are excluded under the medical plans for employees who work for Scripps Mercy Hospital San Diego or Scripps Mercy Hospital Chula Vista. Refer to the Plan Document for more information. * Outpatient advanced imaging includes CT Scan or CAT Scan, MRI and PET Scan. ** Refer to Scripps Medical Plan Summary Plan Documents at MyScrippsHealthPlan.com for information on pre-service review requirements. HMO and EPO Medical Options At-a-Glance The table below highlights the key benefits available under the HMO and EPO medical options. Please refer to the plan documents online at MyScrippsHealthPlan.com for a complete description of benefits, exclusions, limitations, and more. EPO plan members can visit MyScrippsHealthPlan.com to verify deductibles, out of pocket maximums and benefits, or to request a digital ID card.
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