Page 65 - New Hire Kit (Non-Union)
P. 65

Summary of Benefits                                                  Palomar Health HMO NG 1 L

      Covered Benefits cont.                                                                              Copayments
     Family Planning Services
     Injectable contraceptives (including but not limited to Depo Provera)                                        $0
     Voluntary sterilization - women                                                                              $0
     Voluntary sterilization - men                                                                            variable 4
     Interruption of pregnancy                                                                                variable 4
     Infertility services (diagnosis and treatment of underlying condition)
       Office visit/counseling                                                                        $25 per visit copay
     Treatment/Surgery
             Physician/Surgery charges                                                          Member coinsurance 30% 4
                                                                                                         Plan pays 70%
             Inpatient facility                                                                  $250 per admission copay
             Outpatient facility                                                                 $100 per admission copay
         Injectable infertility drugs                                                                         variable 4
     Durable Medical Equipment and Other Supplies
     Durable medical equipment                                                                                   $50
     Diabetic supplies                                                                                            $0
     Prosthetics and orthotics                                                                                    $0
     Mental Health Services
     Diagnosis and treatment of Severe Mental Illnesses for all members and Serious Emotional Disturbances for children, and any mental health
     condition identified as a "mental disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM
     IV), are covered with the cost-sharing listed below. 6
     Office visits                                                                                          $20 / visit
     Group therapy                                                                                          $20 / visit
     Other outpatient items and sevices                                                                     $20 / visit
     Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism     $10 / visit
     Inpatient facility fee                                                                            $250 / admission
     Inpatient physician fee                                                                                      $0
     Emergency services facility fee (waived if admitted)                                                   $100 / visit
     Emergency services physician fee (waived if admitted)                                                        $0
     Emergency psychiatric transportation                                                                        $50
     Non-emergency psychiatric transportation                                                                    $50
     Urgent care services                                                                                   $30 / visit
     Chemical Dependency Services
     Office visits                                                                                          $20 / visit
     Group therapy                                                                                          $20 / visit
     Other outpatient items and sevices                                                                     $20 / visit
     Inpatient facility fee                                                                            $250 / admission
     Inpatient physician fee                                                                                      $0
     Emergency services facility fee for acute alcohol or drug detoxification (waived if admitted)          $100 / visit
     Emergency services physician fee for acute alcohol or drug detoxification (waived if admitted)               $0
     Emergency substance use disorder transportation                                                             $50
     Non-emergency substance use disorder transportation                                                         $50
     Urgent care services                                                                                   $30 / visit
     Skilled Nursing, Home Health and Hospice Services
       Skilled nursing facility services (maximum of 100 days per benefit period)                        $0 / admission
     Home health services (cost share per visit - maximum of 100 visits per calendar year)                  $10 / visit
     Hospice care - inpatient                                                                                     $0
     Hospice care - outpatient                                                                                    $0













  Tel: Toll-Free 1-800-359-2002 | www.SharpHealthPlan.com | 01.01.20 | Palomar Health HMO NG 1 L | 20/25/250 | 20638 |
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