Page 78 - 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: POS

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)

Not covered by Not covered by
If you need drugs to Preferred generic drugs Sharp Health Plan Sharp Health Plan

treat your illness or
condition Not covered by Not covered by Administered by CVS Caremark
More information about Preferred brand drugs Sharp Health Plan Sharp Health Plan 800-776-1355 / Caremark.com

prescription drug
coverage is available at Not covered by Not covered by
www.sharphealthplan.com Non-preferred drugs Sharp Health Plan Sharp Health Plan

Facility fee (e.g., $125 copay/procedure; 20% coinsurance
ambulatory surgery center) deductible does not apply
If you have outpatient Preauthorization is required.
surgery No charge/visit; Precertification applies Out-of-Network.
Physician/surgeon fees deductible does not apply 20% coinsurance

$100 copay/visit; $100 copay/visit; Cost sharing waived if admitted to the
Emergency room care
deductible does not apply deductible does not apply hospital.

Emergency medical $50 copay/trip; $50 copay/trip;
transportation deductible does not apply deductible does not apply None
If you need immediate
medical attention Services must be approved by your primary

care provider and received at urgent care
$35 copay/visit; $35 copay/visit; facilities affiliated with your Plan Medical
Urgent care
deductible does not apply deductible does not apply 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;
room) deductible does not apply 20% coinsurance Preauthorization is required for non-
If you have a hospital emergency services. Out-of-network services
stay No charge/visit; are covered for emergency care only.

Physician/surgeon fees deductible does not apply 20% coinsurance Precertification applies Out-of-Network.

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Palomar Health POS NG 1 L / ACCH15_40 / VSA0