Page 28 - New Hire Kit (Union)

2020 Benefits at a glance

Effective Jan. 1, 2020

Plan Options

Health
Maintenance High Deductible Point of Service (POS)
Organization Plan (HMO)
(HMO)NG1L

Non-Union Only Tier 1 Tier 2
$0 $1,500 / self-only $0 $250 / individual
Annual Deductible $2,700 / individual $750 / family
$3,000 / family

$2,000 / individual $3,000 / individual $2,000 / individual $3,000 / individual
Annual Out-of-Pocket Maximum
$4,000 / family $6,000 / family $4,000 / family $6,000 / family
Well Baby and Well Child $0 per visit $0 per visit $0 per visit 20% coinsurance*
Physical Exam

Routine Adult Physical Exam $0 per visit $0 per visit $0 per visit 20% coinsurance*

Primary Care Physician Visit $20 per visit $30 per visit* $30 per visit 20% coinsurance*

Specialist Physician Visit $25 per visit $30 per visit* $35 per visit 20% coinsurance*

Urgent Care Services $30 per visit $40 per visit* $35 per visit $35 per visit

Emergency Room Services $100 per visit $100 per visit* $100 per visit $100 per visit*

Outpatient Surgery $100 per procedure $150 per procedure* $125 per procedure 20% coinsurance*

Hospitalization (inpatient services) $250 admission $250 per day* $250 admission 20% coinsurance*

Mental Health Services
Inpatient $250 admission $100 per day* $250 admission 20% coinsurance*
Outpatient $20 per visit $30 per visit* $30 per visit 20% coinsurance*

Chiropractic / Acupuncture services $15 per visit $15 per visit $15 per visit Not covered
(with American Specialty Health Network) (limit 40 visits per year) (limit 40 visits per year) (limit 40 visits per year)

*After deductible has been met, this copayment will apply.

Sharp Health Plan 1–800-359-2002 | sharphealthplan.com