Page 49 - New Hire Kit (Non-Union)
P. 49

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)


                                                                                                                                                                                  Preauthorization is required.  Coverage is
                                                            Home health care                       $30 copay/visit                          Not covered                           limited to short-term, intermittent services,
                                                                                                                                                                                  100 visits/calendar year.

                           If you need help                                                                                                                                       Preauthorization is required.  Includes

                           recovering or have                                                      $30 copay/visit                          Not covered                           physical therapy, speech therapy, and
                           other special health             Rehabilitation services                                                                                               occupational therapy.
                           needs


                                                            Habilitation services                  Not covered                              Not covered                           Not covered


                                                                                                                                                                                  Preauthorization is required. Coverage is
                                                            Skilled nursing care                   $200 copay/admission                    Not covered
                                                                                                                                                                                  limited to 100 days/calendar year.


                                                            Durable medical equipment              50% coinsurance                          Not covered                           Preauthorization is required.




                                                                                                   Inpatient:

                                                                                                   $200 copay/admission
                                                            Hospice services                                                                Not covered                           Preauthorization is required.
                                                                                                   Outpatient:
                                                                                                   $50 copay/day


                                                                                                                                                                                  Eye exams are covered once every 24

                                                                                                                                                                                  months.  Cost sharing for covered
                                                            Children’s eye exam                    $30 copay/visit                          Not covered
                                                                                                                                                                                  supplemental vision services do not count
                                                                                                                                                                                  towards the out–of–pocket limit.
                           If your child needs
                           dental or eye care                                                                                                                                     Limitations apply.  Cost sharing for covered
                                                            Children’s glasses                     Discounted                               Not covered                           supplemental vision services do not count
                                                                                                                                                                                  towards the out–of–pocket limit.


                                                            Children’s dental check-up             Not covered                              Not covered                           Not covered












                                                                                                                                                                                                                                5 of 11
                                                                                                                                                                             Palomar Health HMO NG 2 L / ACCH15_40 / VSA8
   44   45   46   47   48   49   50   51   52   53   54