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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)

 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.











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                                       Palomar Health HMO NG 1 L / ACCH15_40 / VSA8
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