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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)

                                                    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
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