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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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                                             Palomar Health POS NG 1 L / ACCH15_40 / VSA0
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