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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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