Page 101 - New Hire Kit (Non-Union)
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Summary of Benefits                                                            Palomar Health POS NG 1 L

                                                                                Tier 1:                Tier 2:
                                                                                                          1
     Covered Benefits, continued                                            HMO Benefit Level  Out-of-Network Benefit Level
     Family Planning Services
     Injectable contraceptives (including but not limited to Depo Provera)  $0                          20% after deductible
     Voluntary sterilization - women                                   $0                               20% after deductible
                                                                       $35/physician office visit or
     Voluntary sterilization - men                                                         5            20% after deductible
                                                                       $250/inpatient hospital admission
                                                                       $125/outpatient surgery visit or
     Interruption of pregnancy                                                             5            20% after deductible 7
                                                                       $250/inpatient hospital admission
     Infertility Services (diagnosis and treatment of underlying condition)
     Office visit/counseling                                           $35/visit                             Not covered
     Treatment/Surgery                                                                                       Not covered
          Physician/Surgeon charges                                    30%**                                 Not covered
          Inpatient facility                                           $250/admission                        Not covered
          Outpatient facility                                          $125/admission                        Not covered
                                                                       Variable based on type and location of
          Injectable infertility drugs                                                                       Not covered
                                                                       service, not to exceed $45
     Durable Medical Equipment and Other Supplies
     Durable medical equipment                                         $50                              20% after deductible 7
     Diabetic supplies                                                 $0                               20% after deductible
     Prosthetics and orthotics                                         $0/visit                         20% after deductible 7
     Mental Health Services
     Diagnosis and treatment of Severe Mental Illnesses for all members and Serious Emotional Disturbances for children, and any mental health condition identified as a
     "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV), are covered with the cost-sharing listed below. 6
     Office visits                                                     $30/visit                        20% after deductible
     Group therapy                                                     $30/visit                        20% after deductible
     Other outpatient items and sevices                                $30/visit                        20% after deductible
     Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism  $10   20% after deductible
     Inpatient facility fee                                            $250/admission                   20% after deductible 7
     Inpatient physician fee                                           $0                               20% after deductible 7
     Emergency services facility fee (waived if admitted)              $100/visit                  $100/visit (deductible waived)
     Emergency services physician fee (waived if admitted)             $0                                          $0
     Emergency psychiatric transportation                              $50                                        $50
     Non-emergency psychiatric transportation                          $50                                        $50
     Urgent care services                                              $35/visit                               $35/visit
     Chemical Dependency Services
     Office visits                                                     $30/visit                        20% after deductible
     Group therapy                                                     $30/visit                        20% after deductible
     Other outpatient items and sevices                                $30/visit                        20% after deductible
     Inpatient facility fee                                            $250/admission                   20% after deductible 7
     Inpatient physician fee                                           $0                               20% after deductible 7
     Emergency services facility fee for acute alcohol or drug detoxification (waived if admitted)  $100/visit  $100/visit (deductible waived)
     Emergency services physician fee for acute alcohol or drug detoxification (waived if admitted)  $0            $0
     Emergency substance use disorder transportation                   $50                                        $50
     Non-emergency substance use disorder transportation               $50                                        $50
     Urgent care services                                              $35/visit                               $35/visit
     Skilled Nursing, Home Health  and Hospice Services
     Skilled nursing facility services (combined maximum of 100 visits per calendar year in and out of network)  $0   20% after deductible 7

     Home health services (combined maximum of 100 visits per calendar year in and out of network)  $10   20% after deductible 7
     Hospice care - inpatient                                          $0                               20% after deductible 7
     Hospice care - outpatient                                         $0                               20% after deductible 7
     Prescription Drug Coverage (Administered by CVS Caremark 800-776-1355 / Caremark.com)
                                                                       Not covered by                                                             Not covered by
     Preferred Generic/Preferred Brand/Non-preferred medications up to 30 day supply
                                                                       Sharp Health Plan                  Sharp Health Plan
     Preferred Generic/Preferred Brand/Non-preferred medications for a 90 day supply by mail order (for   Not covered by                                                             Not covered by
     maintenance medications only)                                     Sharp Health Plan                  Sharp Health Plan
                                                                       Not covered by                                                             Not covered by
     Preventive prescription drugs including Preferred Generic and prescribed over-the-counter contraceptives
                                                                       Sharp Health Plan                  Sharp Health Plan
     Supplemental Benefits 1
       Chiropractic and Acupuncture services (maximum of 40 visits combined per calendar year)  $15 / visit  Not covered
                                                                                               $40 allowance                             for
       Vision services (once every 12 months / Exam only)              $0
                                                                                                         Non-VSP provider







  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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