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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: 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)



                                                             Facility fee (e.g., ambulatory           $100 copay/procedure                   Not covered
                                                             surgery center)
                             If you have

                             outpatient surgery                                                                                                                                    Preauthorization is required.

                                                             Physician/surgeon fees                   No charge/visit                        Not covered





                                                                                                                                                                                   Cost sharing waived if admitted to the
                                                             Emergency room care                      $100 copay/visit                       $100 copay/visit
                                                                                                                                                                                   hospital.




                                                             Emergency medical
                             If you need                     transportation                           $50 copay/trip                         $50 copay/trip                        None
                             immediate medical
                             attention                                                                                                                                             Services must be approved by your primary

                                                                                                                                                                                   care provider and received at urgent care
                                                                                                                                                                                   facilities affiliated with your Plan Medical
                                                             Urgent care                              $30 copay/visit                        $30 copay/visit
                                                                                                                                                                                   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                   $250 copay/admission

                             If you have a                   room)                                                                                                                 Preauthorization is required for non-
                                                                                                                                                                                   emergency services. Out-of-network services
                             hospital stay                                                                                                                                         are covered for emergency care only.
                                                             Physician/surgeon fees                   No charge/visit                        No charge/visit



























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                                                                                                                                                                        Palomar Health HMO NG 1 L / ACCH15_40 / VSA8
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