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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: HDHP HMO
Common Services You May Need What You Will Pay Limitations, Exceptions, & Other Important
Medical Event In Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Preauthorization is required. Coverage is
Home health care $30 copay/visit Not covered limited to short-term, intermittent services,
100 visits/calendar year.
If you need help Preauthorization is required. Includes
recovering or have $30 copay/visit Not covered physical therapy, speech therapy, and
other special health Rehabilitation services occupational therapy.
needs
Habilitation services Not covered Not covered Not covered
Preauthorization is required. Coverage is
Skilled nursing care $200 copay/admission Not covered
limited to 100 days/calendar year.
Durable medical equipment 50% coinsurance Not covered Preauthorization is required.
Inpatient:
$200 copay/admission
Hospice services Not covered Preauthorization is required.
Outpatient:
$50 copay/day
Eye exams are covered once every 24
months. Cost sharing for covered
Children’s eye exam $30 copay/visit Not covered
supplemental vision services do not count
towards the out–of–pocket limit.
If your child needs
dental or eye care Limitations apply. Cost sharing for covered
Children’s glasses Discounted Not covered supplemental vision services do not count
towards the out–of–pocket limit.
Children’s dental check-up Not covered Not covered Not covered
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Palomar Health HMO NG 2 L / ACCH15_40 / VSA8
