Page 122 - New Hire Kit (Non-Union)
P. 122

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





                                                                                                                                                                                                                                5 of 11

                                                                                                                                                                              Palomar Health POS NG 1 L / ACCH15_40 / VSA0
   117   118   119   120   121   122   123   124   125   126   127