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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: HDHP HMO




                                      All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.


                                    Common                                                                                   What You Will Pay                                    Limitations, Exceptions, & Other Important

                                Medical Event                 Services You May Need                      In Network Provider                 Out-of-Network Provider                                   Information
                                                                                                       (You will pay the least)               (You will pay the most)


                                                            Primary care visit to treat

                                                            an injury or illness                   $30 copay/visit                          Not covered                           None



                                                                                                                                                                                  Preauthorization is required, except for
                                                            Specialist visit                       $30 copay/visit                          Not covered
                                                                                                                                                                                  obstetric gynecologic services.


                                                                                                                                                                                  Acupuncture/Chiropractic coverage is limited
                                                                                                                                                                                  to 40 combined visits/calendar year without
                           If you visit a health                                                   Acupuncture/Chiropractic:                                                      preauthorization.

                           care provider’s office                                                  $15 copay/visit;
                           or clinic                        Other practitioner office visit        deductible does not apply                Not covered                           Cost sharing for covered supplemental

                                                                                                                                                                                  Acupuncture/Chiropractic services do not

                                                                                                                                                                                  count towards the out–of–pocket limit.




                                                                                                                                                                                  You may have to pay for services that
                                                            Preventive care/screening/             No charge;                               Not covered                           aren’t preventive. Ask your provider if the

                                                            immunization                           deductible does not apply                                                      services you need are preventive. Then
                                                                                                                                                                                  check what your plan will pay for.



                                                            Diagnostic test (x-ray,                $10 copay/visit (blood work)
                                                            blood work)                            $10 copay/visit (x-rays)                 Not covered                           None

                           If you have a test

                                                            Imaging (CT/PET scans,
                                                            MRIs)                                  $50 copay/procedure                      Not covered                           Preauthorization is required.

















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                                                                                                                                                                             Palomar Health HMO NG 2 L / ACCH15_40 / VSA8
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