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.
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** |
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 |