Page 122 - 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)

Preauthorization is required. Coverage is

$10 copay/admission; limited to short-term, intermittent
Home health care 20% coinsurance
deductible does not apply services, 100 visits/calendar year.
Precertification applies Out-of-Network.

Preauthorization is required. Includes

If you need help $15 copay/visit; physical therapy, speech therapy, and

recovering or have other Rehabilitation services deductible does not apply 20% coinsurance occupational therapy.
special health needs Precertification applies Out-of-Network.

Habilitation services Not covered Not covered Not covered

Preauthorization is required. Coverage is
No charge/admission;
Skilled nursing care 20% coinsurance limited to 100 days/calendar year.
deductible does not apply
Precertification applies Out-of-Network.
$50 copay; Preauthorization is required.
Durable medical equipment deductible does not apply 20% coinsurance Precertification applies Out-of-Network.

Inpatient:

No charge/admission; Inpatient:
deductible does not apply 20% coinsurance Preauthorization is required.
Hospice services
Outpatient: Outpatient: Precertification applies Out-of-Network.
No charge/visit; 20% coinsurance
deductible does not apply

Eye exams are covered once every 12
$40 allowance for months. Cost sharing for covered
Children’s eye exam No charge/visit
Non-VSP provider supplemental vision services do not count
towards the out–of–pocket limit.
If your child needs

dental or eye care Limitations apply. Cost sharing for covered
Children’s glasses Discounted Not covered supplemental vision services do not count
towards the out–of–pocket limit.

Children’s dental check-up Not covered Not covered Not covered

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Palomar Health POS NG 1 L / ACCH15_40 / VSA0