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Summary of Benefits                                                            Palomar Health POS NG 1 L

    THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY.  THE EVIDENCE OF COVERAGE AND PLAN
    CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.  PLEASE CONTACT YOUR EMPLOYER FOR
    SPECIFIC INFORMATION ON  YOUR COVERAGE OR  VISIT WWW.SHARPHEALTHPLAN.COM TO VIEW THE MEMBER HANDBOOK.
                                                                                Tier 1:                Tier 2:
                                                                                                          1
     Covered Benefits                                                       HMO Benefit Level  Out-of-Network Benefit Level
     Annual Deductible and Out of Pocket Maximum
                                                                                                               2
     Calendar year medical deductible (per individual/per family) 3    $0                                   $250  / $750 2
                                                                           2
                                                                                                              2
      Annual out of pocket maximum - including medical and prescription drugs (per individual/per family) 3  $2,000  / $4,000 2   $3,000  / $6,000 2
     Lifetime Maximum
     There are no lifetime maximums for this plan                      Unlimited                              Unlimited
       Preventive Care 4
     Well-baby and well-child (to age 18) physical exams, immunizations and related laboratory services   $0   20% after deductible
     Routine adult physical exams, immunizations and related laboratory services  $0                    20% after deductible
     Laboratory, radiology, and other services for the early detection of disease when ordered by a Physician  $0   20% after deductible
     Routine gynecological exams, immunizations and related laboratory services  $0                     20% after deductible
     Mammography                                                       $0                               20% after deductible
     Prostate cancer screening                                         $0                               20% after deductible
     Colorectal cancer screenings including sigmoidoscopy and colonoscopy  $0                           20% after deductible
             SM
     Best Health  Wellness Services
     On-line health education and wellness workshops and other wellness tools  $0                                  $0
     Telephonic health coaching (weight management, tobacco cessation, stress management, physical activity,   $0   $0
     nutrition)
     Routine Care
     Vision Exam - Routine (Limited to 1 visit every 12 months) 3      $0                               20% after deductible
     Adult Hearing Exam (Limited to 1 visit every 2 years) 3           $0                               20% after deductible
     Professional Services
     Primary Care Physician office visit for consultation, treatments, diagnostic testing, etc.  $30/visit  20% after deductible
     Specialist Physician office visit for consultation, treatments, diagnostic testing, etc.  $35/visit  20% after deductible
     Laboratory services                                               $0                               20% after deductible
     Radiology services (x-rays)                                       $0                               20% after deductible
     Advanced radiology (including but not limited to MRI, MRA, MRS, CT scan, PET, MUGA, SPECT)   $0    20% after deductible 7
     Allergy testing                                                   $10/visit                        20% after deductible
     Allergy injections                                                $10/visit                        20% after deductible
     Injectable and specialty medications                              $35 copay 5                      20% after deductible 7
     Outpatient Services (including but not limited to surgical, diagnostic and therapeutic services)
     Outpatient facility fee                                           $125/visit                       20% after deductible 7
     Physician/Surgeon fee                                             $0                               20% after deductible 7
     Infusion therapy (including but not limited to chemotherapy)      $35/specialist office visit 5    20% after deductible
     Dialysis                                                          $0                               20% after deductible
     Physical, occupational and speech therapy                         $15/visit                        20% after deductible 7
     Habilitation services                                             Not covered                            Not covered
                                                                       $0 if received in an outpatient hospital   20% after deductible
     Radiation therapy                                                                                                                                           5
                                                                       setting
     Hospitalization (including but not limited to inpatient services, organ transplant, and inpatient rehabilitation)
     Facility fee                                                      $250/admission                   20% after deductible 7
          Inpatient services                                           $250/admission                   20% after deductible 7
          Organ transplant                                             $250/admission                   20% after deductible 7
          Inpatient rehabilitation                                     $0                               20% after deductible 7
          Bariatric surgery                                            $250/admission                   20% after deductible 7
     Physician/surgeon fee
          Inpatient services                                           $0                               20% after deductible 7
          Organ transplant                                             $0                               20% after deductible 7
          Inpatient rehabilitation                                     $0                               20% after deductible 7
          Bariatric surgery                                            $0                               20% after deductible 7
     Emergency and Urgent Care Services
     Emergency room services (waived if admitted to the hospital)      $100/visit                  $100/visit (deductible waived)
     Urgent care services                                              $35/visit                               $35/visit
     Medical Transportation
     Emergency medical transportation                                  $50                                        $50
     Non-emergency medical transportation                              $50                                        $50
       Maternity Care
     Prenatal and postpartum office visits                             $0/visit                         20% after deductible
     Delivery and all inpatient services - Hospital                    $250/admission                   20% after deductible 7
     Delivery and all inpatient services - Professional                $0                               20% after deductible 7
       Breastfeeding support, supplies and counseling                  $0                                    Not covered





  Tel: Toll-Free 1-800-359-2002 | www.SharpHealthPlan.com | 01.01.20 | Palomar Health POS NG 1 L | 30/250/250ded/20% | 20640 |
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