Feature	EPO Plan
Who directs and provides your care	Scripps Custom Network (Out of network services not covered)
Annual Deductible	$0
Annual Out of Pocket Max (includes all copayments)	$3,000 per person $6,000 per family
Lifetime Maximum	Unlimited
Primary Care Physician Visit	$25 copay ($35 copay if no PCP is designated)
Specialist Visit	$40 copay
Hospitalization	Scripps Custom Network Hospitals only
Outpatient Surgical Facility	100% (after $200 copay)
Inpatient Semi-Private Room	100% (after $300 copay per admission)
Inpatient Physician	100%
Urgent Care	$50 copay
Emergency Room	$200 copay (waived if admitted)
Health Maintenance and Preventive Services	$0 copay
Allergy Treatment Testing Injections/Serum	$25 copay $10/visit
Diagnostic Lab/X-Ray	Lab & X-Ray 100% Advanced Imaging*: $150 copay ($450 copay max per calendar year)
Durable Medical Equipment	100% after $300 copay
Outpatient Treatment (i.e., PT, OT)	$30 copay (Precert after 24 combined visits)
Acupunture Chiro	100% after $25 copay 20 visit combined maximum per calendar year
Mental Health/Chemical Dependency
Outpatient	$25 copay
Inpatient	100% after $300 copay per admission (Network Only)

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

Drug Type	MedImpact Retail Pharmacy (30 day supply)	Choice 90 Pharmacy Retail Pharmacy (90 day supply)	Mail Service Pharmacy (90 day supply)
Annual Out-of-Pocket Maximum*	EPO Plan: $4,150 per person; $8,300 per family
Generic	$15 copay	$30 copay	$30 copay
High Cost Generic (cost over $50 with relevant alternatives)	$40 copay	$100 copay	$100 copay
Preferred/Formulary	$40 copay	$100 copay	$100 copay
Non-Preferred/Non-Formulary	$70 copay	$210 copay	$210 copay
Specialty Medications	When filled at Modern Health Pharmacy: 30% coinsurance per prescription (minimum $100, maximum $200); prior authorization required; When filled through the Care Partner program: $0 copay

Drug Type	MedImpact Retail Pharmacy (30 day supply)	Choice 90 Pharmacy Retail Pharmacy (90 day supply)	Mail Service Pharmacy (90 day supply)
Annual Out-of-Pocket Maximum*	$2,500 per person; $5,000 per family
Generic	$10 copay	$20 copay	$20 copay
High Cost Generic (cost over $50 with relevant alternatives)	$35 copay	$87.50 copay	$87.50 copay
Preferred/Formulary	$35 copay	$87.50 copay	$87.50 copay
Non-Preferred/Non-Formulary	$55 copay	$165 copay	$165 copay
Specialty Medications	When filled at MedImpact: 25% coinsurance per prescription (minimum $75, maximum $150); prior authorization required; When filled through the Care Partner program: $0 copay

Feature	Anthem Dental Complete Network Provider	All Other Providers
Annual Deductible per Individual	$50 (waived for diagnostic & preventive services)	$100 (waived for diagnostic & preventive services)
Maximum Benefit per Year	$1,800 per individual (excluding Orthodontia)
Diagnostic & Preventive Services Exams, cleanings and x-rays	100% *	90% **
Basic Services Oral Surgery, Extractions, Fillings	80% *	70% **
Major Services Crowns, bridges & dentures	50% *	40% **
Cosmetic Dentistry Dental implants only	N/A	N/A
Orthodontic Services (no age limit) $1,800 lifetime maximum per individual	50% *	50% **

Feature	Anthem Dental Complete Network Provider	All Other Providers
Annual Deductible per Individual	$50 (waived for diagnostic & preventive services)	$100 (waived for diagnostic & preventive services)
Maximum Benefit per Year	$2,200 per individual (excluding Orthodontia)
Diagnostic & Preventive Services Exams, cleanings and x-rays	100% *	90% **
Basic Services Oral Surgery, Extractions, Fillings	80% *	70% **
Major Services Crowns, bridges & dentures	60% *	50% **
Cosmetic Dentistry Dental implants only	60% *	50% **
Orthodontic Services (no age limit) $2,000 lifetime maximum per individual	50% *	50% **

Feature	Core Vision Option	Voluntary Buy-up Vision Option
Vision Providers	Benefits shown below assume use of MESVision providers	Benefits shown below assume use of MESVision providers
Eye Exam  (every 12 months)	$10 copay	$10 copay
Frames  (every 24 months)	$100 retail allowance**	$125 retail allowance**
Standard Lenses	Plan pays 100%	Plan pays 100%
Lens Options -U/V, anti-reflective coating	20% discount*	$20 to $125 retail allowance, plus 20% discount for overages*
Contact Lenses*** -Cosmetic or Convenience (every 12 months)	Plan pays up to $105, includes evaluation fitting and/or materials. Balance is your responsibility and a 20% discount is available on additional charges (benefit is in lieu of spectable lenses and frames).	Covered up to $105 Plan pays 100% (benefit is in lieu of spectable lenses and frames)
-Medically necessary (every 12 months)	Contact Lenses Medically Necessary is covered 100% (benefit is in lieu of spectable lenses and frames)	Plan pays 100% (benefit is in lieu of spectable lenses and frames)

Chiropractic and Acupuncture Services	EPO Plan
Office Visits	$25 copay per visit. Up to 20 visits per calendar year for chiropractic and acupuncture services combined.

Chiropractic and Acupuncture Services	HMO Plan
Office Visits	$15 copay per visit. Up to 20 visits per calendar year for chiropractic and acupuncture services combined.

Account Feature	Health Care Spending Account	Dependent Care Spending Account
Your Pre-tax Contributions	Min: $120 per year Max: $2,750 per year	Min: $120 per year Max: $5,000 per year ($2,500 if married and filing separate tax returns)
Eligible Expenses	Expenses for you, your spouse and any dependent you list on your tax return, if expenses have not been reimbursed by other coverages. Example: health plan deductibles, prescription drug and other co-pays, certain charges not covered by any plan	Care expenses for eligible dependents that allow you to work. Eligible dependents include your qualifying child(ren) age 12 and under, your spouse or a qualifying child or relative who is physically or mentally incapable of self-care. Example: daycare, summer day camp