• What are the Scripps Medical Plans?
• How do the Plans Work?
• How much will my co-payment be for physician office visits?
• How can I get information about participating providers?
• If my provider is not currently on the list of participating providers, how can I get him or her added to the network?
• What about covered family members who live in another state?
• What type of prescription drug benefit does each plan offer?
• What does TPL stand for?
• Why is it important? What are some examples of TPL incidents?
• What is the member's responsibilities regarding TPL?

What are the Scripps Medical Plans?
The Scripps Medical Plans are employer-funded medical plans, offered to eligible employees, COBRA participants and early retirees of Scripps Health. The plans offer a choice of two different plan designs. Scripps employees, COBRA participants and early retirees may enroll in either the EPO Medical Plan or the PPO Medical Plan.

How do the Plans Work?
Scripps EPO Medical Plan - This plan option offers the highest coverage level at the lowest cost and features office visit copays for primary care and specialists. There is no deductible and most medically necessary services are covered at 100%. Certain services require pre-authorization. Members must contact the Scripps Medical Plans Member Solution Center to obtain pre-authorization prior to receiving services.

PPO Medical Plan – When you select the PPO plan you have the option at the time of service to select from two levels of benefits, Tier 1 and Tier 2.

When you receive services from a Tier 1 provider (a Scripps Custom Network Provider) you receive the Tier 1 level of benefits which offers a higher level of coverage ($100 deductible, 100% for in-patient hospital and 80% for physician services).

When you receive services from a Tier 2 provider (a National PPO Network Provider) you receive the Tier 2 level of benefits which offers a lower level of coverage ($400 deductible, and 60% coverage for most medically necessary services).

How much will my co-payment be for physician office visits?
The EPO Medical Plan - PCP office visit benefit is a $10 copayment and the specialist office visit copayment is $30. You must visit Scripps Custom Provider Network providers.

The PPO Medical Plan - Tier 1 - PCP office visit benefit is 80% coverage after you meet a $100 deductible. You must visit a Scripps Custom Provider Network PCP.

The PPO Medical Plan – Tier 2 - Office visit benefit is 60% coverage after you meet a $400 deductible.

How can I get information about participating providers?
1. You can go on-line to the Home Page of this Web site and click on the "Provider Network" link. You will have the option to look at the Scripps Custom Provider Network or a National PPO Provider Network, Schaller Anderson Behavioral Health of California for Mental Health Providers, American Specialty Health Plan (ASHP) for alternative medicine providers, and MESVision for vision service providers.

2. You may call the Scripps Medical Plans Member Solution Center at (888) 897-4988 to locate a provider in your area.

3. You may request a copy of the Scripps Custom Network Provider Directory from your Human Resources Department.

If my provider is not currently on the list of participating providers, how can I get him or her added to the network?
If you do not see your provider listed, please contact the Scripps Medical Plans Member Solution Center at (888) 897-4988. We will assist you in completing a Provider Nomination form and submit it to the Provider Services Department on your behalf.

What about covered family members who live in another state?
If an eligible member's dependent resides more than 30 miles from a Scripps Custom Network PCP, the dependent may qualify for the Out-of-Area plan. The enrolled employee must contact the Scripps Medical Plans Member Solution Center to enroll eligible dependents in the plan. Under the Out-of-Area plan, the eligible dependent may receive EPO benefits from the Scripps Custom Provider Network or a National Provider Network.

What type of prescription drug benefit does each plan offer?
The Scripps Medical Plans offer coverage for generic and brand name medications. Please refer to the Summary of Benefits for coverage information or visit www.express-scripts.com.

What does TPL stand for? Why is it important?
TPL stands for Third Party Liability; this means another party, other than your Scripps Medical Plan, may be responsible to pay for medical expenses related to a TPL incident.

What are some examples of TPL incidents?
Some examples are motor vehicle accidents, slip and fall, dog bites, assault, malpractice or any medical condition related to possible negligence.

What is the member's responsibility regarding TPL?
It is the member's responsibility to notify the Scripps Medical Plans Member Solution Center if a TPL incident occurs and to respond to any inquiry letters from Recovery Management Services promptly and completely. Failure to do so may result in reversal of any paid claims related to the incident and denial of any future claims related to the incident.