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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services   Coverage Period: 01/01/2020 – 12/31/2020

 Sharp Health Plan: Palomar Health                                          Coverage for: Individual / Family | Plan Type: POS




   All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.


 Common    What You Will Pay                              Limitations, Exceptions, & Other

 Medical Event   Services You May Need   In Network Provider   Out-of-Network Provider   Important Information
 (You will pay the least)   (You will pay the most)


 Primary care visit to treat   $30 copay/visit;              20% coinsurance   None
 an injury or illness   deductible does not apply


 $35 copay/visit;                                   Preauthorization is required, except for
 Specialist visit   20% coinsurance
 deductible does not apply                          obstetric gynecologic services.

                                                    Acupuncture/Chiropractic coverage is

                                                    limited to 40 combined visits/calendar year

 If you visit a health care   Acupuncture/Chiropractic:   without preauthorization.
 provider’s office or   Other practitioner office visit   $15 copay/visit;                         Not covered

 clinic   deductible does not apply                 Cost sharing for covered supplemental
                                                    Acupuncture/Chiropractic services do not

                                                    count towards the out–of–pocket limit.



                                                    You may have to pay for services that aren’t
 Preventive care/screening/   No charge;                          20% coinsurance   preventive. Ask your provider if the services

 immunization   deductible does not apply           you need are preventive. Then check what
                                                    your plan will pay for.


 No charge/visit (blood work);

 Diagnostic test (x-ray,   deductible does not apply   20% coinsurance (blood work)    None
 blood work)   No charge/visit (x-rays);   20% coinsurance (x-rays)
 If you have a test   deductible does not apply



 Imaging (CT/PET scans,   No charge/procedure;      Preauthorization is required.

 MRIs)    deductible does not apply   20% coinsurance   Precertification applies Out-of-Network.
















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                                             Palomar Health POS NG 1 L / ACCH15_40 / VSA0
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