Page 121 - New Hire Kit (Non-Union)

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