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HMO Plan Overview

For your medical health needs, you may elect HMO coverage through Scripps Health Plan. At the time of enrollment, you will be required to choose a Primary Care Physician (PCP) for yourself and each of your family members. Your PCP will have at least one plan medical group, and some may have multiple affiliations to choose from.

The Scripps Health Plan HMO network is made of six medical groups consisting of thousands of providers located throughout San Diego County:

  • Mercy Physicians Medical Group (MPMG)
  • Primary Care Associates Medical Group (PCAMG)
  • Scripps Clinic Medical Group (SCMG)
  • Scripps Coastal Medical Center (SCMC)
  • Scripps Physicians Medical Group (SPMG)
  • Rady Childrens Health Network (RCHN)

Members use our vast network of quality providers to select a Primary Care Physician (PCP) who coordinates their health care, maintains their medical records, provides routine care and refers members to specialists and other services when medically necessary.

Services by providers that are not in the Scripps Health Plan Network are not covered, except in the case of an emergency.

For more information on prior authorization requirements please click the “Prior Authorization” tab on the left side of this page. The table below highlights key benefits and your out of pocket responsibility under the HMO medical option. Refer to the "Medical Plan Documents" section on the menu bar to the left for a complete description of benefits, exclusions, limitations and more.

Feature Basic EPO Plan Scripps Health Plan HMO for 2021
Who Directs and Provides Your Care? SHP Contracted Network SHP Contracted Network
Who Adjudicates Your Claims? Scripps Health Plan Services Scripps Health Plan
Calendar Year Deductible $0 $0
Calendar Year Out-of-Pocket Maximum
(includes all copayments)
$1,500 per person / $3,000 per family $1,500 per person / $3,000 per family
Lifetime Maximum Unlimited Unlimited
Primary Care Physician Visit $15 copay $15 copay
Specialist Visit $25 copay $25 copay
Hospitalization
Outpatient Surgery
Inpatient
ScrippsHealth Plan Network Hospitals Only
Covered 100% after $100 copay
Covered 100% after $250 copay/admit
SHPS Network Hospitals Only
Covered 100% after $100 copay
Covered 100% after $250 copay/admit
Urgent Care $35 copay $35 copay
Emergency Room $150 copay (waived if admitted) $150 copay (waived if admitted)
Inpatient Physician 100% 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

$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Allergy Treatment Testing: $15 copay/visit

Injections/Serum: $10/visit
Testing: $15 copay/visit

Injections/Serum: $10/visit
Diagnostic Lab/X-Ray Lab & X-Ray: $0 copay

Advanced Imaging: $100 copay
Lab & X-Ray 100%

Advanced Imaging: $100 copay
Durable Medical Equipment Covered 100% after $250 copay Covered 100% after $250 deductible
Outpatient Treatment
(i.e., PT, OT, SP)
$25 copay $25 copay
Prescription Drugs
Deductible $0 $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)
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)
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 $2,500 per person / $5,000 per family
Mental Health/Substance Abuse Cigna Behavioral Health-CA
Outpatient $15 copay $15 copay
Inpatient $250 per stay $250 per stay
 

See Plan Documents for full details. Copayment and co-insurance paid under Medical Eye Services (MES) and prescription copays do not apply to the annual out-of-pocket maximum.