Page 49 - New Hire Kit (Non-Union)
P. 49

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



 Common    Services You May Need   What You Will Pay   Limitations, Exceptions, & Other Important

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


 If you need drugs to   Not covered by                      Not covered by
 treat your illness or   Preferred generic drugs    Sharp Health Plan   Sharp Health Plan
 condition

 More information   Not covered by                      Not covered by                      Administered by CVS Caremark
 about prescription   Preferred brand drugs   Sharp Health Plan   Sharp Health Plan   800-776-1355 / Caremark.com

 drug coverage is
 available at
 www.sharphealthplan.  Non-preferred drugs    Not covered by                      Not covered by

 com   Sharp Health Plan   Sharp Health Plan


 Facility fee (e.g.,   Not covered
 If you have   ambulatory surgery center)   $150 copay/procedure   Preauthorization is required.

 outpatient surgery
 Physician/surgeon fees   No charge/visit   Not covered



                                                Cost sharing waived if admitted to the
 Emergency room care   $100 copay/visit   $100 copay/visit
                                                hospital.




 Emergency medical
 If you need   transportation   $100 copay/trip   $100 copay/trip   None

 immediate medical
 attention                                      Services must be approved by your primary
                                                care provider and received at urgent care

                                                facilities affiliated with your Plan Medical
 Urgent care   $40 copay/visit    $40 copay/visit
                                                Group. Out-of-Network services are covered

                                                only when you are outside of the Service Area
                                                for your Plan Network.


 Facility fee (e.g., hospital   $250 copay/day   $250 copay/day
 If you have a   room)                          Preauthorization is required for non-

 hospital stay                                  emergency services. Out-of-network services
                                                are covered for emergency care only.
 Physician/surgeon fees   No charge/visit   No charge/visit








                                                                                              3 of 11

                                           Palomar Health HMO NG 2 L / ACCH15_40 / VSA8
   44   45   46   47   48   49   50   51   52   53   54