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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)


                                                                                                    Mental Health/Substance                  Mental Health/Substance
                                                                                                    Use Disorder                             Use Disorder


                                                                                                    Office visits:                           Office visits:
                                                                                                    $30 copay/visit                          20% coinsurance                          Preauthorization is required. *Applies to

                                                              Outpatient services                                                                                                     intensive outpatient program and partial
                                                                                                    Group therapy:                           Group therapy:                           hospitalization program.
                                                                                                    $30 copay/visit                          20% coinsurance


                        If you need mental                                                          Other outpatient services*:              Other outpatient services*:
                        health, behavioral                                                          $30 copay/visit                          20% coinsurance
                        health, or substance

                        abuse services                                                              Mental Health/Substance                  Mental Health/Substance
                                                                                                    Use Disorder                             Use Disorder
                                                                                                                                                                                      Preauthorization is required for non-
                                                                                                    $250 copay/admission                     20% coinsurance

                                                                                                    (facility fee);                          (facility fee/physician fee)             emergency services. Out-of-network services
                                                              Inpatient services                                                                                                      are covered for emergency care only.
                                                                                                    deductible does not apply


                                                                                                    No charge/visit                                                                   Precertification applies Out-of-Network.
                                                                                                    (physician fee);

                                                                                                    deductible does not apply

                                                                                                    No charge/visit;

                                                              Office visits                         deductible does not apply                20% coinsurance                          Cost sharing does not apply to certain
                                                                                                                                                                                      preventive services. Depending on the type

                                                                                                                                                                                      of services, a copayment, coinsurance, or
                                                              Childbirth/delivery                   No charge/visit;                         20% coinsurance                          deductible (if applicable) may apply.

                        If you are pregnant                   professional services                 deductible does not apply                                                         Maternity care may include tests and services

                                                                                                                                                                                      described elsewhere in the SBC (i.e.
                                                                                                                                                                                      ultrasound).Out-of-network services are
                                                              Childbirth/delivery facility  $250 copay/admission;                                                                     covered for emergency care only.

                                                              services                              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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