Page 31 - New Hire Kit (Non-Union)

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 |