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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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