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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



                                    Common                      Services You May Need                                          What You Will Pay                                           Limitations, Exceptions, & Other

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


                                                                                                    Not covered by                      Not covered by
                        If you need drugs to                  Preferred generic drugs               Sharp Health Plan                        Sharp Health Plan

                        treat your illness or
                        condition                                                                   Not covered by                      Not covered by                                Administered by CVS Caremark
                        More information about                Preferred brand drugs                 Sharp Health Plan                        Sharp Health Plan                        800-776-1355 / Caremark.com

                        prescription drug
                        coverage is available at                                                    Not covered by                      Not covered by
                        www.sharphealthplan.com  Non-preferred drugs                                Sharp Health Plan                        Sharp Health Plan




                                                              Facility fee (e.g.,                   $125 copay/procedure;                    20% coinsurance
                                                              ambulatory surgery center)  deductible does not apply
                        If you have outpatient                                                                                                                                        Preauthorization is required.
                        surgery                                                                     No charge/visit;                                                                  Precertification applies Out-of-Network.
                                                              Physician/surgeon fees                deductible does not apply                20% coinsurance




                                                                                                    $100 copay/visit;                        $100 copay/visit;                        Cost sharing waived if admitted to the
                                                              Emergency room care
                                                                                                    deductible does not apply                deductible does not apply                hospital.



                                                              Emergency medical                     $50 copay/trip;                        $50 copay/trip;
                                                              transportation                        deductible does not apply                deductible does not apply                None
                        If you need immediate
                        medical attention                                                                                                                                             Services must be approved by your primary

                                                                                                                                                                                      care provider and received at urgent care
                                                                                                    $35 copay/visit;                     $35 copay/visit;                     facilities affiliated with your Plan Medical
                                                              Urgent care
                                                                                                    deductible does not apply                deductible does not apply                Group. Out-of-Network services are
                                                                                                                                                                                      covered only when you are outside of the
                                                                                                                                                                                      Service Area for your Plan Network.


                                                              Facility fee (e.g., hospital          $250 copay/admission;
                                                              room)                                 deductible does not apply                20% coinsurance                          Preauthorization is required for non-
                        If you have a hospital                                                                                                                                        emergency services. Out-of-network services
                        stay                                                                        No charge/visit;                                                                  are covered for emergency care only.

                                                              Physician/surgeon fees                deductible does not apply                20% coinsurance                          Precertification applies Out-of-Network.










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