Page 31 - New Hire Kit (Non-Union)
P. 31

Summary of Benefits                                                    Palomar Health HMO NG 2 L

    Covered Benefits cont.                                                                                 Copayments
     Maternity Care
    Prenatal and postpartum office visits                                                                          $0
    Delivery and all inpatient services - Hospital                                                           $250 / day 8
    Delivery and all inpatient services - Professional                                                             $0 8
    Breastfeeding support, supplies and counseling                                                                                                                         $0
    Family Planning Services
    Injectable contraceptives (including but not limited to Depo Provera)                                          $0
    Voluntary sterilization - women                                                                                $0
    Voluntary sterilization - men                                                                             variable 4,8
    Interruption of pregnancy                                                                                 variable 4,8
    Infertility services (diagnosis and treatment of underlying condition)
      Office visit/counseling                                                                          $30 per visit copay 8
      Treatment/Surgery
                                                                                                  Member coinsurance 50% 5,8
            Physician/Surgery charges
                                                                                                           Plan pays 50%
            Inpatient facility                                                                         $250 per day copay 8
            Outpatient facility                                                                   $150 per procedure copay 8
        Injectable infertility drugs                                                                          variable 4,8
    Durable Medical Equipment and Other Supplies
    Durable medical equipment                                                                           50% coinsurance 6,8
    Diabetic supplies                                                                                   20% coinsurance 6,8
    Prosthetics and orthotics                                                                                $30 / visit 8
    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. 7
    Office visits                                                                                            $30 / visit 8
    Group therapy                                                                                            $30 / visit 8
    Other outpatient items and services                                                                      $30 / visit 8
    Inpatient facility fee                                                                                   $100 / day 8
    Inpatient physician fee                                                                                        $0 8
    Emergency services facility fee (waived if admitted)                                                    $100 / visit 8
    Emergency services physician fee (waived if admitted)                                                          $0 8
    Emergency psychiatric transportation                                                                         $100 8
    Non-emergency psychiatric transportation                                                                     $100 8
    Urgent care services                                                                                     $40 / visit 8
    Chemical Dependency Services
    Office visits                                                                                            $30 / visit 8
    Group therapy                                                                                            $30 / visit 8
    Other outpatient items and services                                                                      $30 / visit 8
    Inpatient facility fee                                                                                   $100 / day 8
    Inpatient physician fee                                                                                        $0 8
    Emergency services facility fee for acute alcohol or drug detoxification (waived if admitted)           $100 / visit 8
    Emergency services physician fee for acute alcohol or drug detoxification (waived if admitted)                 $0 8
    Emergency substance use disorder transportation                                                              $100 8
    Non-emergency substance use disorder transportation                                                          $100 8
    Urgent care services                                                                                     $40 / visit 8
    Skilled Nursing, Home Health and Hospice Services
     Skilled nursing facility services (maximum of 100 days per benefit period)                         $200 / admission 8
    Home health services (cost share per visit - maximum of 100 visits per calendar year)                    $30 / visit 8
    Hospice care - inpatient                                                                            $200 / admission 8
    Hospice care - outpatient                                                                                 $50 / day 8






  Tel: (858) 499-8300 or 1-800-359-2002 | www.SharpHealthPlan.com | 01.01.20 | Palomar HMO NG 2 L | 1500ded/30/30 | 20639 |
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