Feature |
Scripps Health Plan HMO for 2021 |
Who Directs and Provides Your Care? |
SHP Contracted Network |
Who Adjudicates Your Claims? |
Scripps Health Plan |
Calendar Year Deductible |
$0 |
Calendar Year Out-of-Pocket Maximum
(includes all copayments) |
$1,500 per person / $3,000 per family |
Lifetime Maximum |
Unlimited |
Primary Care Physician Visit |
$15 copay |
Specialist Visit |
$25 copay |
Hospitalization
Outpatient Surgery
Inpatient
|
SHPS Network Hospitals Only
Covered 100% after $100 copay
Covered 100% after $250 copay/admit |
Urgent Care |
$35 copay |
Emergency Room |
$150 copay (waived if admitted) |
Inpatient Physician |
100% |
Preventive (age & frequency schedules apply)
Well Child Care
Immunizations
Well Woman Exams
Mammograms
Routine Preventive Care |
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay |
Allergy Treatment |
Testing: $15 copay/visit
Injections/Serum: $10/visit |
Diagnostic Lab/X-Ray |
Lab & X-Ray 100%
Advanced Imaging: $100 copay |
Durable Medical Equipment |
Covered 100% after $250 deductible |
Outpatient Treatment
(i.e., PT, OT, SP) |
$25 copay |
Prescription Drugs |
Deductible |
$0 |
Retail Pharmacy
Generic
High Cost Generic
Preferred /Formulary
Non-Preferred /Non-Formulary
Specialty Medications |
30-day supply
$10 copay
$35 copay
$35 copay
$55 copay
25% coinsurance ($75 min/$150 max)
(Prior Authorization Req'd) |
Mail Order
Generic
High Cost Generic
Preferred /Formulary
Non-Preferred /Non-Formulary
Specialty Medications |
90-day supply Care Partner Program
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
|
90-day supply All Other Mail Order
$20 copay
$87.50 copay
$87.50 copay
$165 copay
25% coinsurance ($75 min/$150 max)
(Prior Authorization Req'd)
|
Prescription Drugs - OOP Maximum |
$2,500 per person / $5,000 per family |
Mental Health/Substance Abuse |
Cigna Behavioral Health-CA |
Outpatient |
$15 copay |
Inpatient |
$250 per stay |