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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



 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)

 Mental Health/Substance   Mental Health/Substance

 Use Disorder    Use Disorder

 Office visits:   Office visits:

 $30 copay/visit   Not covered
                                                Preauthorization is required. *Applies to

 Outpatient services   Group therapy:   Group therapy:   intensive outpatient program and partial
 $30 copay/visit   Not covered                  hospitalization program.


 If you need mental   Other outpatient services*:   Other outpatient services*:
 health, behavioral   $30 copay/visit   Not covered

 health, or substance
 abuse services


 Mental Health/Substance   Mental Health/Substance
 Use Disorder    Use Disorder

                                                Preauthorization is required for non-
 $100 copay/day    $100 copay/day
 Inpatient services                             emergency services. Out-of-network services
 (facility fee);    (facility fee);             are covered for emergency care only.

 No charge/visit                  No charge/visit

 (physician fee)    (physician fee)


 No charge/visit;
 Office visits   deductible does not apply   Not covered   Cost sharing does not apply to certain
                                                preventive services. Depending on the type of
                                                services, a copayment, coinsurance, or


 If you are pregnant   Childbirth/delivery   No charge/visit   No charge/visit   deductible (if applicable) may apply.
 professional services                          Maternity care may include tests and services
                                                described elsewhere in the SBC (i.e.

 Childbirth/delivery facility   $250 copay/day   $250 copay/day   ultrasound). Out-of-network services are

 services                                       covered for emergency care only.










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                                           Palomar Health HMO NG 2 L / ACCH15_40 / VSA8
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