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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)


                                                             Primary care visit to treat an
                                                             injury or illness                        $20 copay/visit                        Not covered                           None


                                                                                                                                                                                   Preauthorization is required, except for
                                                             Specialist visit                         $25 copay/visit                        Not covered
                                                                                                                                                                                   obstetric gynecologic services.

                                                                                                                                                                                   Acupuncture/Chiropractic coverage is

                                                                                                                                                                                   limited to 40 combined visits/calendar year

                             If you visit a health                                                    Acupuncture/Chiropractic:                                                    without preauthorization.
                             care provider’s                 Other practitioner office visit          $15 copay/visit                        Not covered
                             office or clinic                                                                                                                                      Cost sharing for covered supplemental

                                                                                                                                                                                   Acupuncture/Chiropractic services do not

                                                                                                                                                                                   count towards the out–of–pocket limit.



                                                                                                                                                                                   You may have to pay for services that

                                                             Preventive care/screening/                                                                                            aren’t preventive. Ask your provider if
                                                             immunization                             No charge                              Not covered                           the services you need are preventive.
                                                                                                                                                                                   Then check what your plan will pay for.


                                                             Diagnostic test (x-ray, blood  No charge/visit (blood work)

                                                             work)                                    No charge/visit (x-rays)               Not covered                           None
                             If you have a test
                                                             Imaging (CT/PET scans,                   No charge/procedure                    Not covered                           Preauthorization is required.
                                                             MRIs)



                             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.c           Non-preferred drugs                      Not covered by                      Not covered by
                             om.                                                                      Sharp Health Plan                      Sharp Health Plan





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