For application developers

Scripps Health Plan has partnered with its Pharmacy Benefit Manager, MedImpact, to provide access to a Real-Time Pharmacy Benefit Check (RTPBC) application programming interface (API). The RTPBC provides prescription drug cost and coverage information. If you are a third-party application developer and would like to access the RTPBC API, please submit your request to MedImpact.

What you need to know about the cost of covered items and services

Centers for Medicare & Medicaid Services’ Transparency in Coverage Rule requires health insurers and group health plans to provide cost-sharing data to consumers. This data will be available on our website by the individual deadlines imposed by this Rule. 


Data will be available as follows:

Machine-readable files

These files will be published monthly beginning July 1, 2022, for Scripps Health Plan benefit plan years beginning on or after January 1, 2022. The file makes available negotiated payment rates for covered items and services based on in-network negotiated payment rates and historical out-of-network allowed amounts. Requirements and a due date for a prescription drug file are pending. 


In-Network 

These machine-readable monthly files will provide negotiated rates for all covered items and services between the health plan and In-Network Providers.



Out-of-Network

These machine-readable monthly files will provide historical payment information, including billed and allowed amounts to and from Out-of-Network Providers.


Consumer price transparency tool

We’ve made it easy to receive an estimate through our Cost Calculator tool on MyScripps. Simply log in to use your insurance information on file and quickly find out your cost share (out-of-pocket costs) for certain procedures or tests. All your finalized estimates are available to you in MyScripps. You may also contact Scripps Health Plan Customer Service at 844-337-3700 with any questions.


Log in

List of services and items / cost share

Routine Services

Location of Service

Types of Services

Your Cost Share

Physician Office

Office visits

Office-based procedures

$0 for Maternity Care

$0 for Preventive Care (well-child exams, well woman exams, immunizations)

$0 for Contraceptive Injections and IUDs

$20 for Primary and Mental Health Care per visit

$35 for Specialty Care per visit

Physician Office

Allergy Testing

$15 for Allergy Testing per visit

$10 for Allergy Injections/Serum per visit

Outpatient Diagnostic Services, Surgery and Treatment Procedures

Location of Service

Types of Services

Your Cost Share

Hospital - Outpatient or Free-Standing Outpatient Centers

Dialysis

$0 for Dialysis per visit

Hospital - Outpatient or Free-Standing Outpatient Centers

Infertility Treatment

50% of all covered facility charges

Hospital - Outpatient or Free-Standing Outpatient Centers

Infusion Therapy

$0 for Infusion Therapy per visit

Hospital - Outpatient or Free-Standing Outpatient Centers

Rehabilitation Therapy

$30 for Rehabilitation Therapy

(Cardiac, Occupational, Physical, Pulmonary, Speech) per visit

Hospital - Outpatient or Free-Standing Outpatient Centers

Radiology/Imaging

$0 for General Radiology (X-ray) per test

$0 for Mammograms per test

$150 for Advanced Imaging (MRI, CT Scan, PET Scan) per test

Hospital - Outpatient or Free-Standing Outpatient Centers

Radiation Therapy

$0 for Radiation Therapy per visit

Hospital - Outpatient or Free-Standing Outpatient Centers

Surgical/Diagnostic Procedures

$0 for Abortion

$0 for Colorectal Screening per visit 

$0 for Tubal Ligation

$0 for Vasectomy

$200 for Surgery/Diagnostic Procedures per visit

Laboratory

Lab work

$250 for genetic testing

$0 for all other lab tests

Emergent/Urgent Services

Location of Service

Types of Services

Your Cost Share

Ambulance

Transportation to the Emergency Department

$150 per ambulance trip

Emergency Department

Emergency care needs

$150 for Emergency Department Visit*

Urgent Care Center

Urgent care needs

$40 for Urgent Care Visit**

*Additional services provided outside of the Emergency Department may result in an additional copay (e.g., Advanced Imaging). The Emergency Department copay is waived if you are admitted and the hospital admission copay will apply. 

**Additional services provided outside of the Urgent Care Center may result in an additional copay (e.g., Advanced Imaging)

Hospitalization

Location of Service

Types of Services

Your Cost Share

Hospital - Inpatient

Admission to Inpatient Care

$300 per hospital stay for any reason

Skilled Nursing Facility

100 day max per member, per calendar year, prior authorization required

$0 copay/admission

Equipment/Supplies

Types of Equipment/Supplies

Your Cost Share

Breast pumps

$0

Diabetic supplies

$0

Hearing aids

$150 per set every 36 months

All other types of medically necessary equipment and supplies

$250 annual deductible