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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: HMO



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

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


 Primary care visit to treat an
 injury or illness   $20 copay/visit     Not covered   None


                                                  Preauthorization is required, except for
 Specialist visit   $25 copay/visit    Not covered
                                                  obstetric gynecologic services.

                                                  Acupuncture/Chiropractic coverage is

                                                  limited to 40 combined visits/calendar year

 If you visit a health   Acupuncture/Chiropractic:   without preauthorization.
 care provider’s   Other practitioner office visit   $15 copay/visit    Not covered
 office or clinic                                 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/                       aren’t preventive. Ask your provider if
 immunization   No charge    Not covered          the services you need are preventive.
                                                  Then check what your plan will pay for.


 Diagnostic test (x-ray, blood  No charge/visit (blood work)

 work)   No charge/visit (x-rays)   Not covered   None
 If you have a test
 Imaging (CT/PET scans,   No charge/procedure   Not covered   Preauthorization is required.
 MRIs)



 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.c  Non-preferred drugs    Not covered by                      Not covered by
 om.   Sharp Health Plan   Sharp Health Plan





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                                       Palomar Health HMO NG 1 L / ACCH15_40 / VSA8
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