Page 47 - 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: 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