Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: 01/01/2020 – 12/31/2020

Scripps Medical Plan EPO: Scripps Custom Network

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to www.MyScrippsHealthPlan.com or call 1-
877-552-7247.For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined
terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call 1-877-552-7247 to request a copy.
Important Questions Answers Why This Matters:
Generally, you must pay all of the costs from providers up to the deductible amount before this plan
What is the overall $0 begins to pay. If you have other family members on the plan, each family member must meet their
deductible? own individual deductible until the total amount of deductible expenses paid by all family members
meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a
Are there services
copayment or coinsurance may apply. For example, this plan covers certain preventive services
covered before you meet N/A. There is no deductible.
without cost-sharing and before you meet your deductible. See a list of covered preventive services
your deductible?
at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
Yes. $300 for Durable Medical You must pay all of the costs for these services up to the specific deductible amount before this
deductibles for specific
Equipment and Prosthetics. plan begins to pay for these services.
services?
Medical: $3,000 individual / The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
What is the out-of-pocket
$6,000 family; Prescription Drugs: family members in this plan, they have to meet their own out-of-pocket limits until the overall family
limit for this plan?
$4,150 individual / $8,300 family: out-of-pocket limit has been met. There is a separate out-of-pocket limit for Prescription Drugs.
Premiums, balance-billing
What is not included in charges, health care this plan
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
the out-of-pocket limit? doesn’t cover and penalties for not
obtaining prior authorization.
You must use network providers,
except in the event of an This plan uses a provider network. If you use an in-network doctor or other health care provider, this
Will you pay less if you emergency. See plan will pay some or all of the costs of covered services. Be aware, your network provider might
use a network provider? www.MyScrippsHealthPlan.com or use an out-of-network provider for some services (such as lab work). Check with your provider
call 1-877-552-7247 for a list of before you get services.
network providers.
No. You may self-refer to any
Do you need a referral to
provider within the Scripps You can see the network specialist you choose without permission from this plan.
see a specialist?
Custom Network.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Released on April 6, 2016 1 of 6
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
$25 copay/visit if you
Designation of a Primary Care Physician is
designate a Primary
Primary care visit to treat an required for the lowest copay and you can see
Care Physician (PCP); Not Covered
injury or illness any Network Primary Care Physician for a
$35 copay/visit if you do
If you visit a health $25 copay.
not designate a PCP
care provider’s office
Specialist visit $40 copay/visit Not Covered None
or clinic
You may have to pay for services that aren’t
Preventive care/screening/ preventive. Ask your provider if the services
No Charge Not Covered
immunization you need are preventive. Then check what
your plan will pay for.
Diagnostic test (x-ray, blood Outpatient radiology services must be
No Charge Not Covered
work) performed at a Scripps Imaging Center facility
If you have a test except basic x-rays and OB ultra-sounds
Imaging (CT/PET scans, MRIs) $150 copay/test Not Covered performed in a physician’s office, and pediatric
services. $450 copay maximum/calendar year.
$15 copay/30 day Covers up to a 30-day supply (retail
Supply; prescription) when using a MedImpact Retail
Generic drugs (Tier 1) Not Covered
$30 copay/90 day Pharmacy (excluding Walgreens); 31-90 day
supply supply (mail order prescription) when using the
High cost generic drugs (high $40 copay/30 day Scripps Direct Pharmacy. No charge for oral
cost generics have relevant Supply; contraceptives.
If you need drugs to Not Covered
alternatives and cost more than $100 copay/90 day
treat your illness or $50) supply Specialty Drugs are subject to a minimum
condition
$40 copay/30 day copay of $100 and a maximum copay of $200
More information about
supply; for those living outside of San Diego County.
prescription drug Preferred brand drugs (Tier 2) Not Covered
$100 copay/90 day
coverage is available at
supply Specialty Drugs are subject to a minimum
www.[insert].com
$70 copay/30 day copay of $100 and a maximum copay of $300
Non-preferred brand drugs supply; for those living within San Diego County.
Not Covered
(Tier 3) $210 copay/90 day
supply Prior Authorization is required for Specialty
30% coinsurance/ drugs.
Specialty drugs (Tier 4) Not Covered
prescription

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 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Scripps Custom Network Hospitals Only; Prior
Facility fee (e.g., ambulatory
If you have outpatient $200 copay Not Covered Authorization may be required – refer to the
surgery center)
surgery Summary Plan Document.
Physician/surgeon fees No Charge Not Covered None
Emergency room care $200 copay $200 copay
Emergency room care copay waived if
If you need immediate Emergency medical
$150 copay $150 copay admitted. Non-emergency use of emergency
medical attention transportation
services not covered.
Urgent care $50 copay/visit Not Covered
Scripps Custom Network Hospitals Only; Prior
If you have a hospital Facility fee (e.g., hospital room) $300 copay/admission Not Covered
Authorization required or $250 penalty.
stay
Physician/surgeon fees No Charge Not Covered None
Outpatient Services: Anthem Blue Cross
Outpatient services $25 copay/office visit Not Covered
Network services only. Prior Authorization may
If you need mental
be required – refer to the Summary Plan
health, behavioral
Document.
health, or substance
Inpatient services $300 copay/admission Not Covered Inpatient services: Acute inpatient facility only,
abuse services
not residential facilities; Prior Authorization
required or $250 penalty.
Office visits $40 copay Not Covered Office visits: copay applies to the first visit only.
Childbirth/delivery professional Facility: Scripps Custom Network Hospitals
No Charge Not Covered
services Only; Prior Authorization required for stays
If you are pregnant
exceeding those outlined in the Newborns’ and
Childbirth/delivery facility
$300 copay/admission Not Covered Mothers’ Health Protection Act – refer to the
services
Summary Plan Document.
When ordered by a physician and subject to
Home health care No Charge Not Covered
Prior Authorization or $250 penalty.
Rehabilitation services $30 copay Not Covered Pre-service review required after 24 combined
therapy visits. Not all habilitation services are
If you need help
Habilitation services $25 copay Not Covered covered – refer to the Summary Plan
recovering or have
Document.
other special health
When ordered by a physician and subject to
needs
Skilled nursing care No Charge Not Covered Prior Authorization or $250 penalty. Limited to
100 days/calendar year.
Separate $300 calendar year deductible
Durable medical equipment No Charge Not Covered
applies to durable medical equipment and

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 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
prosthetics – refer to the Summary Plan
Document.
For a person who is terminally ill with a life
Hospice services No Charge Not Covered
expectancy of 6 months or less.
Limited to one exam per 12 months. Maximum
Children’s eye exam $10 copay/visit $10 copay/visit Plan payment for non-network providers is
$40.
No charge for standard Partial payment depending Limited to one set of lenses per 12 months;
If your child needs
lenses and frames. on lens type. See Summary one set of frames per 24 months.
dental or eye care Children’s glasses
Plan Document for details.

Must enroll in a separate dental plan for dental

Children’s dental check-up Not Covered Not Covered
coverage.

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Cosmetic Surgery
• Non-emergency care when traveling outside the
• Dental Care • Weight Loss Programs
U.S.
• Long Term Care • Routine Foot Care
• Private Duty Nursing

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture (if prescribed for rehabilitation
• Chiropractic Care
purposes) • Infertility Treatment
• Hearing Aids
• Bariatric Surgery

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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. For more information on your rights to continue coverage, contact the plan at 1-877-552-7247.
You may also contact your state insurance department, the California Department of Insurance. Other coverage options may be available to you too, including buying
individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-
2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: 1-877-552-7247.

Does this plan provide Minimum Essential Coverage? Yes.

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? Yes.

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-877-552-7247.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-552-7247.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-552-7247.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-552-7247.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $0  The plan’s overall deductible $500  The plan’s overall deductible $0
 Specialist copayment $40  Specialist copayment $50  Specialist copayment $40
 Hospital (facility) copay $300  Hospital (facility) coinsurance 20%  Hospital (facility) copay $200
 Other coinsurance 0%  Other coinsurance 20%  Other coinsurance 0%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles* $60 Deductibles* $200
Copayments $360 Copayments $1,200 Copayments $500
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $20 Limits or exclusions $60 Limits or exclusions $0
The total Peg would pay is $380 The total Joe would pay is $1,320 The total Mia would pay is $700

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to
reduce your costs. For more information about the wellness program, please contact: [insert].
*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?” row above.

The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6