Page 83 - New Hire Kit (Non-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)

Mental Health/Substance Mental Health/Substance

Use Disorder Use Disorder

Office visits: Office visits:

$20 copay/visit Not covered
Preauthorization is required. *Applies to
Outpatient services intensive outpatient program and partial
Group therapy: Group therapy:
$20 copay/visit Not covered hospitalization program.

If you need mental Other outpatient services*: Other outpatient services*:
health, behavioral $20 copay/visit Not covered
health, or substance

abuse services
Mental Health/Substance Mental Health/Substance

Use Disorder Use Disorder

$250 copay/admission $250 copay/admission Preauthorization is required for non-

Inpatient services (facility fee); (facility fee); emergency services. Out-of-network services
are covered for emergency care only.
No charge/visit No charge/visit

(physician fee) (physician fee)

Office visits No charge/visit Not covered
Cost sharing does not apply to certain

preventive services. Depending on the type
Childbirth/delivery No charge/visit No charge/visit of services, a copayment, coinsurance, or
professional services deductible (if applicable) may apply.
If you are pregnant
Maternity care may include tests and services
described elsewhere in the SBC (i.e.

Childbirth/delivery facility ultrasound). Out-of-network services are
services $250 copay/admission $250 copay/admission covered for emergency care only.

4 of 11
Palomar Health HMO NG 1 L / ACCH15_40 / VSA8