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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: HDHP HMO



                                    Common                    Services You May Need                                          What You Will Pay                                    Limitations, Exceptions, & Other Important

                                Medical Event                                                            In Network Provider                 Out-of-Network Provider                                   Information
                                                                                                       (You will pay the least)               (You will pay the most)


                           If you need drugs to                                                    Not covered by                      Not covered by
                           treat your illness or            Preferred generic drugs                Sharp Health Plan                        Sharp Health Plan
                           condition

                           More information                                                        Not covered by                      Not covered by                             Administered by CVS Caremark
                           about prescription               Preferred brand drugs                  Sharp Health Plan                        Sharp Health Plan                     800-776-1355 / Caremark.com

                           drug coverage is
                           available at
                           www.sharphealthplan.             Non-preferred drugs                    Not covered by                      Not covered by

                           com                                                                     Sharp Health Plan                        Sharp Health Plan


                                                            Facility fee (e.g.,                                                             Not covered
                           If you have                      ambulatory surgery center)             $150 copay/procedure                                                           Preauthorization is required.

                           outpatient surgery
                                                            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                         $100 copay/trip                          $100 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                            $40 copay/visit                          $40 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/day                           $250 copay/day
                           If you have a                    room)                                                                                                                 Preauthorization is required for non-

                           hospital stay                                                                                                                                          emergency services. Out-of-network services
                                                                                                                                                                                  are covered for emergency care only.
                                                            Physician/surgeon fees                 No charge/visit                          No charge/visit








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                                                                                                                                                                             Palomar Health HMO NG 2 L / ACCH15_40 / VSA8
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