Page 9 - Palomar EE Guide 01-19 FINAL

Health & Wellness

Plan Name POS

Tier 1 Tier 2
Health Benefits
Who Directs and Provides Your Care Your PCP or PCP referred provider Any licensed Tier 2 provider (discounted
services provided with preferred provider
network)
Annual Deductible
- Employee Only Coverage $0 $250/person
- Other Coverage $0 $750/family
Annual Out-of-Pocket Maximum
(all co-pays except Chiropractic and Acupuncture)
- Employee Only Coverage $2,000/person $3,000/person
- Other Coverage $4,000/family $6,000/family

Lifetime Maximum Unlimited Unlimited
Preventive Care (routine physical, well visits (baby or $0 co-pay After deductible, 80% coverage*
child), immunizations and related labs, cancer
screenings, routine OBGYN, mammography)

Physician Office Visits
- Primary Care Physician $30 co-pay After deductible, 80% coverage*
- Specialist $35 co-pay After deductible, 80% coverage*
- Prenatal and Postpartum $0 co-pay After deductible, 80% coverage*
- Outpatient Mental Health / Substance Abuse $30 co-pay After deductible, 80% coverage*
Hospitalization Choice Network Hospitals Any Hospital

- Inpatient Semi-Private Room $250/admission (covered by Palomar After deductible, 80% coverage*
Health if services received at Palomar
Health)

- Outpatient Surgery $125/surgery (covered by Palomar Health After deductible, 80% coverage*
if services received at Palomar Health)

- Inpatient Mental Health $250/admission (covered by Palomar After deductible, 80% coverage*
Health if services received at Palomar
Health)

Medical Transportation $50 co-pay $50 co-pay
Emergency Room $100 co-pay $100 co-pay

Urgent Care $35 co-pay $35 co-pay
Diagnostic X-Ray and Lab 100% coverage through your PCP or PCP After deductible, 80% coverage*
referred provider
Rehab Therapy (physical, occupational, speech, $15 co-pay After deductible, 80% coverage*
cardiac)
*If you use a Tier 2 in-network provider, you will likely save money. Non-network providers may cause you to be billed for the difference between the
approved amount and the provider’s billed amount (in addition to any applicable coinsurance or deductible).

9