Feature	EPO Plan 2026
Primary Care Physician Visit	$30 copay ($40 copay if no PCP is designated)
Specialist Visit	$45 copay
Preventive Care Such as routine physicals, immunizations, well-child care, well-woman exams, mammograms	$0 copay (age & frequency schedules apply)
Annual Out-of-Pocket Maximum	$3,000 per person; $6,000 per family
Surgery & Hospitalization
Outpatient Surgery	100% (after $250 copay)
Hospitalization • Inpatient Semi-Private Room • Inpatient Physician	Scripps Custom Network Hospitals only $200 copay per admission $0 copay
Urgent & Emergency Care
Urgent Care	$55 copay
Emergency Room	$200 copay (waived if admitted)
Ambulance	$150 copay
Other Services
Diagnostic Lab/X-Ray • Lab & X-ray • Advanced Imaging*	$0 copay $150 copay ($450 copay max/yr)
Physical & Occupational Therapy**	$35 copay
Allergy Serum • Testing • Injections/Serum	$25 copay $10 copay/visit
Durable Medical Equipment	100% after $300 deductible
Chiropractic & Acupuncture Care	Care provided by Anthem Blue Cross $30 copay (20 combined visits per year)
Mental Health/Chemical Dependency*
• Who directs and provides your care • Outpatient visit • Inpatient	Anthem Blue Cross behavioral health providers $30 copay (Network only) $300 copay per admission
* Advanced imaging includes CT Scan or CAT Scan, MRI and PET Scan. ** Refer to Scripps Medical Plan Summary Plan Document at MyScrippsHealthPlan.com for information on pre-service review requirements.

Feature	Scripps Health Plan HMO 2025
Who Directs and Provides Your Care?	Scripps HMO Network
Annual Deductible	$0
Annual Out-of-Pocket Maximum	$1,500 per person; $3,000 per family
Out-of-Area Service	Not covered unless urgent or emergency medical care is required or prior authorization is received for services not performed within the network
Physician Services
Primary Care Physician Visit	$20 copay
Specialist Visit	$35 copay
Preventative Care Such as routine physicals, immunizations, well-child care, well-woman exams, mammograms	$0 copay (age & frequency schedules apply)
Surgery & Hospitalization
Outpatient Surgery	$200 copay
Hospitalization • Inpatient Semi-Private Room • Inpatient Physician	Scripps HMO Network Hospitals only $300 copay per admission $0 copay
Urgent & Emergency Care
Urgent Care	$40 copay
Emergency Room	$150 copay (waived if admitted)
Ambulance	$150 copay
Other Services
Diagnostic Lab/X-Ray • Lab & X-ray • Advanced Imaging*	$0 copay $150 copay
Physical & Occupational Therapy**	$30 copay
Allergy Serum • Testing • Injections/Serum	$15 copay $10 copay/visit
Durable Medical Equipment	100% after $250 deductible
Chiropractic & Acupuncture Care	Care provided by American Specialty Health Network $15 copay (20 combined visits per year)
Mental Health/Chemical Dependency**
• Who directs and provides your care • Outpatient visit • Inpatient	Magellan $20 copay (Network only) $300 copay per admission
* Advanced imaging includes CT Scan or CAT Scan, MRI and PET Scan. ** Refer to Scripps Medical Plan Summary Plan Document at MyScrippsHealthPlan.com for information on pre-service review requirements.

Plan Feature	Scripps EPO Option 2025
Prescription Drugs
Annual Out-of-Pocket Prescription Drugs Maximum*	$4,150 per person; $8,300 per family
Retail • Generic • High Cost Generic • Preferred/Formulary • Non-Preferred/Non-formulary • Specialty Medications	30-day supply $20 copay $50 copay $50 copay $90 copay 30% co-insurance ($125 min; $250 max) if you live and work outside San Diego County, or 30% co-insurance ($125 min; $300 max) if you live or work in San Diego County
Mail Service • Generic • High Cost Generic • Preferred/Formulary • Non-Preferred/Non-formulary	90-day supply $40 copay $125 copay $125 copay $270 copay
* Annual out-of-pocket maximum for prescription drugs is separate from Scripps Medical Plan out-of-pocket maximum.

Plan Feature	Scripps HMO Option 2025
Prescription Drugs
Annual Out-of-Pocket Prescription Drugs Maximum*	$2,500 per person; $5,000 per family
Retail • Generic • High Cost Generic • Preferred/Formulary • Non-Preferred/Non-formulary • Specialty Medications	30-day supply $20 copay $40 copay $40 copay $80 copay 30% co-insurance ($75 min; $250 max)
Mail Service • Generic • High Cost Generic • Preferred/Formulary • Non-Preferred/Non-formulary	90-day supply $40 copay $100 copay $100 copay $225 copay
* Annual out-of-pocket maximum for prescription drugs is separate from Scripps Medical Plan out-of-pocket maximum.

Plan Feature	Scripps EPO Option 2025
Mental Health/Chemical Dependency*
• Who directs and provides care • Outpatient visit • Inpatient	Anthem Blue Cross behavioral health providers $30 copay (Network only) $300 copay per admission
* Refer to Scripps Medical Plan Summary Plan Documents at MyScrippsHealthPlan.com for information on pre-service review requirements.

Plan Feature	Scripps HMO Option 2025
Mental Health/Chemical Dependency*
• Who directs and provides care • Outpatient visit • Inpatient	Magellan $20 copay (Network only) $300 copay per admission
* Refer to Scripps Medical Plan Summary Plan Documents at MyScrippsHealthPlan.com for information on pre-service review requirements.

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% **
* Percentage applies to negotiated fees ** Percentage applies to usual, customary and reasonable charges

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% **
* Percentage applies to negotiated fees ** Percentage applies to usual, customary and reasonable charges

Feature	Core Vision Option	Voluntary Buy-up Vision Option
Vision Providers*	Benefits shown below assume use of EyeMed providers	Benefits shown below assume use of EyeMed providers
Eye Exam (every 12 months)	$10 copay (copay waived at Plus Providers)	$10 copay (copay waived at Plus Providers)
Frames (every 24 months)	$100 retail allowance* ($150 frame allowance at Plus Providers)	$125 retail allowance* ($175 frame allowance at Plus Providers)
Standard Lenses (every 12 months) Single vision, bifocal, trifocal Lenticular Premium progressive (Tier 1-4)	No copay No copay $85, $95, $110, $175 copay	No copay No copay $85, $95, $110, $175 copay
Lens Options Tints U/V treatment Anti-reflective coating Photochromatic Scratch coating Edge coating Polycarbonate (adults) Polycarbonate (children < 19)	$15 copay $15 copay $45-$85 copay $75 copay $15 copay 20% off retail $40 copay No copay	No copay No copay $0-$60 copay $75 copay $0 copay 20% off retail $40 copay No copay
Contact Lenses** Cosmetic or convenience Medically necessary	$105 allowance, 15% off balance Paid in full (in lieu of spectacle lenses, lens options and frame)	$105 allowance, 15% off balance Paid in full (in lieu of spectacle lenses, lens options and frame)
* Retail eyewear benefits will be converted to wholesale-equivalent prices at certain provider locations. Go to eyemed.com for details. ** Contact lens fitting fees — Standard — Up to $40, Premium — 10% off retail price. Contacts are in lieu of lenses only. You are entitled to a full pair of glasses frames & lenses OR contacts and frames.

Chiropractic and Acupuncture Services	EPO Plan 2025
Office Visits	Care provided by Anthem Blue Cross $30 copay (20 combined visits per year)

Chiropractic and Acupuncture Services	HMO Plan 2025
Office Visits	Care provided by American Specialty Health Network $15 copay (20 combined visits per year)

Account Feature	Health Care Spending Account 2026	Dependent Care Spending Account 2026
Your Pre-tax Contributions	Min: $120 per year Max: $3,300 per year	Min: $120 per year Max: $7,500 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