Page 44 - New Hire Kit (Union)

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)

Facility fee (e.g., ambulatory $100 copay/procedure Not covered
surgery center)
If you have

outpatient surgery Preauthorization is required.

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 $50 copay/trip $50 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 $30 copay/visit $30 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/admission $250 copay/admission

If you have a room) Preauthorization is required for non-
emergency services. Out-of-network services
hospital stay are covered for emergency care only.
Physician/surgeon fees No charge/visit No charge/visit

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Palomar Health HMO NG 1 L / ACCH15_40 / VSA8