Small Group Benefit Comparison

(1)

A guide to choosing the right plan for your business

Small Group

Benefit Comparison

(2)

With a range of solutions and

provider networks, we have the

right plan to meet your unique

small business needs.

Sharp Health Plan is your first

choice for access to high-quality,

affordable health care for a

healthy San Diego workforce.

San Diegans choose

Sharp Health Plan

Local focus

As the only local, not-for-profit

commercial health plan, we not only

serve the people of San Diego—we

are

the people of San Diego. When you

join Sharp Health Plan, you’ll have care

options close to where you live and work.

Award-winning care

You’ll receive award-winning care from

our nationally recognized doctors,

medical groups and hospitals. We are

also the highest-rated health plan

1

in

California, and the highest-rated health

plan for customer satisfaction

2

among

reporting California health plans.

Customizable

With a multitude of plan designs, four

provider networks and a broad range of

pricing options, you have the ability to

tailor your plan to your business needs.

(3)

Additional benefits included with every plan

We know that excellent health care is not enough; it must also be easy to access. The convenience of Sharp Health Plan extends

beyond San Diego and standard business hours. All Sharp Health Plan members receive the following value added benefits:

Sharp Nurse Connection

®

We offer an after-hours nurse advice telephone service for

Sharp Health Plan members. When you have a health question or

concern after regular business hours, a single phone call puts you in

touch with a registered nurse.

MinuteClinic

®

As the walk-in medical clinic located inside select CVS/pharmacy®

stores, MinuteClinic provides convenient access to basic care,

without an appointment.

3

Assist America

®

Assist America connects Sharp Health Plan members to doctors,

hospitals, pharmacies and other services when faced with a medical

emergency while traveling 100 miles or more away from home,

or out of the country.

Best Health

Best Health is one of only 10 health plan wellness programs to be

nationally accredited. The program provides Sharp Health Plan

members with a variety of resources from meal plans to exercise

routines to one-on-one personalized health coaching.

1_{The source for this data is Quality Compass}®_{2015 and is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass}®_{2015 includes certain CAHPS}®_data.

Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass®_{is a registered trademark of NCQA. CAHPS}®_{is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Sharp Health Plan achieved the following summary ratings:}

an 81.8 for Rating of the Health Plan compared to the state average of 71.1; an 84.2 for Rating of Health Care compared to the state average of 76.7; an 85.6 for Rating of Personal Doctor compared to the state average of 82.3; an 80.1 for Rating of Health Promotion and Education compared to the state average of 72.1.

2_{Based on the National Committee for Quality Assurance (NCQA) Private Health Insurance Plan Ratings 2015-2016. Sharp Health Plan achieved the following summary scores: 4 out of 5 rating for Customer}

Satisfaction, the only plan in California to do so, and a 4 out of 5 rating overall placing Sharp Health Plan in the top third of health plans nationally.

(4)

Sharp Platinum 90

0 / 10 / 200 Sharp Platinum 90 0 / 15 / 250 Sharp Platinum 90 0 / 20 / 250 Sharp Platinum 90 0 / 20 / 300 Sharp Platinum 90 0 / 20 / 500 A Sharp Platinum 90 0 / 20 / 500 B Sharp Platinum 90 0/20/1000 A Sharp Platinum 90 0/20/1000 B

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) None None None None None None None None

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) None None None None None None None None

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $3,0001_{/ $6,000}1 _$2,9001_{/ $5,800}1 _$2,5001_{/ $5,000}1 _$3,0001_{/ $6,000}1 _$2,0001_{/ $4,000}1 _$3,0001_{/ $6,000}1 _$2,0001_{/ $4,000}1 _$3,0001_{/ $6,000}1

Professional Services

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $10 $15 $20 $20 $20 $20 $20 $20

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $20 $15 $20 $30 $30 $30 $40 $30

Preventive services² $0 $0 $0 $0 $0 $0 $0 $0

Prenatal and postpartum office visits $20 $15 $20 $30 $30 $30 $40 $30

Allergy injections $10 $15 $20 $20 $20 $20 $20 $20

Allergy testing $20 $15 $20 $30 $30 $30 $40 $30

Outpatient Services

Outpatient surgery $100 / procedure $250 / procedure $125 / procedure $300 / procedure $500 / procedure $250 / procedure $500 / procedure $500 / procedure

Radiology services (x-rays and diagnostic imaging) $0 $0 $40 $0 $0 $40 $0 $0

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) $100 $100 $150 $100 $100 $150 $100 $100

Physical, occupational and speech therapy $20 $15 $20 $30 $30 $30 $40 $30

Hospitalization Services

Inpatient $300 / day (3-day max) $250 / day (3-day max) $250 / admission $300 / day (3-day max) $500 / day (3-day max) $500 / admission $1,000 / admission $1,000 / admission

Emergency/Urgent Care Services

Emergency room (waived if admitted for inpatient hospital stay) $100 $100 $100 $100 $100 $100 $150 $100

Urgent care $10 $20 $20 $30 $30 $30 $40 $30

Ambulance Services

Ambulance in connection with hospital admission or emergency services $100 $100 $100 $100 $100 $100 $150 $100

Prescription Drug Coverage

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0 $0 $0 $0 $0

Generic Formulary / Brand Formulary / Non-Formulary medications up to a 30-day supply $15 / $35 / $50 $15 / $35 / $50 $10 / $25 / $50 $19 / $35 / $70 $19 / $35 / $70 $10/ $25 / $50 $15 / $35 / $50 $15 / $35 / $50

Generic Formulary / Brand Formulary / Non-Formulary / Medications up to a 90-day supply by mail order $30 / $70 / $100 $30 / $70 / $100 $20 / $50 / $100 $38 / $70 / $140 $38 / $70 / $140 $20 / $50 / $100 $30 / $70 / $100 $30 / $70 / $100

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0 $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 50% coinsurance3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3

Diabetics supplies 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Prosthetics, orthotics $20 $15 $20 $30 $30 $30 $40 $30

Mental Health Services

Outpatient $20 / visit $15 / visit $20 / visit $30 / visit $30 / visit $30 / visit $40 / visit $30 / visit

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism $20 / visit $15 / visit $20 / visit $30 / visit $30 / visit $30 / visit $40 / visit $30 / visit

Chemical Dependency Services

Emergency services for acute drug or alcohol detoxification $100 / visit $100 / visit $20 / visit $30 / visit $100 / visit $100 / visit $150 / visit $100 / visit

Other

Skilled nursing facility services (maximum of 100 days per benefit period) $100 / day (3-day max) $200 / day (3-day max) $150 / day (5-day max) $200 / day (3-day max) $200 / day (3-day max) $150 / day (5-day max) $200 / admission $200 / admission

Home health services (maximum of 100 visits per calendar year) $20 / visit $15 / visit $20 / visit $30 / visit $30 / visit $30 / visit $40 / visit $30 / visit

Hospice care - inpatient $100 / day (3-day max) $250 / day (3-day max) $200 / day admission $500 / day (3-day max) $500 / day (3-day max) $200 / admission $200 / admission $200 / admission

Hospice care - outpatient $0 $0 $0 $0 $0 $0 $0 $0

Small group Platinum 90 plans

effective January 1, 2016

(5)

Sharp Platinum 90

0 / 10 / 200 Sharp Platinum 90 0 / 15 / 250 Sharp Platinum 90 0 / 20 / 250 Sharp Platinum 90 0 / 20 / 300 Sharp Platinum 90 0 / 20 / 500 A Sharp Platinum 90 0 / 20 / 500 B Sharp Platinum 90 0/20/1000 A Sharp Platinum 90 0/20/1000 B

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) None None None None None None None None

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) None None None None None None None None

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $3,0001_{/ $6,000}1 _$2,9001_{/ $5,800}1 _$2,5001_{/ $5,000}1 _$3,0001_{/ $6,000}1 _$2,0001_{/ $4,000}1 _$3,0001_{/ $6,000}1 _$2,0001_{/ $4,000}1 _$3,0001_{/ $6,000}1

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $10 $15 $20 $20 $20 $20 $20 $20

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $20 $15 $20 $30 $30 $30 $40 $30

Preventive services² $0 $0 $0 $0 $0 $0 $0 $0

Prenatal and postpartum office visits $20 $15 $20 $30 $30 $30 $40 $30

Allergy injections $10 $15 $20 $20 $20 $20 $20 $20

Allergy testing $20 $15 $20 $30 $30 $30 $40 $30

Outpatient Services

Outpatient surgery $100 / procedure $250 / procedure $125 / procedure $300 / procedure $500 / procedure $250 / procedure $500 / procedure $500 / procedure

Radiology services (x-rays and diagnostic imaging) $0 $0 $40 $0 $0 $40 $0 $0

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) $100 $100 $150 $100 $100 $150 $100 $100

Physical, occupational and speech therapy $20 $15 $20 $30 $30 $30 $40 $30

Emergency room (waived if admitted for inpatient hospital stay) $100 $100 $100 $100 $100 $100 $150 $100

Urgent care $10 $20 $20 $30 $30 $30 $40 $30

Ambulance Services

Ambulance in connection with hospital admission or emergency services $100 $100 $100 $100 $100 $100 $150 $100

Prescription Drug Coverage

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0 $0 $0 $0 $0

Generic Formulary / Brand Formulary / Non-Formulary medications up to a 30-day supply $15 / $35 / $50 $15 / $35 / $50 $10 / $25 / $50 $19 / $35 / $70 $19 / $35 / $70 $10/ $25 / $50 $15 / $35 / $50 $15 / $35 / $50

Generic Formulary / Brand Formulary / Non-Formulary / Medications up to a 90-day supply by mail order $30 / $70 / $100 $30 / $70 / $100 $20 / $50 / $100 $38 / $70 / $140 $38 / $70 / $140 $20 / $50 / $100 $30 / $70 / $100 $30 / $70 / $100

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0 $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 50% coinsurance3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3

Diabetics supplies 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Prosthetics, orthotics $20 $15 $20 $30 $30 $30 $40 $30

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism $20 / visit $15 / visit $20 / visit $30 / visit $30 / visit $30 / visit $40 / visit $30 / visit

Emergency services for acute drug or alcohol detoxification $100 / visit $100 / visit $20 / visit $30 / visit $100 / visit $100 / visit $150 / visit $100 / visit

Other

Skilled nursing facility services (maximum of 100 days per benefit period) $100 / day (3-day max) $200 / day (3-day max) $150 / day (5-day max) $200 / day (3-day max) $200 / day (3-day max) $150 / day (5-day max) $200 / admission $200 / admission

Home health services (maximum of 100 visits per calendar year) $20 / visit $15 / visit $20 / visit $30 / visit $30 / visit $30 / visit $40 / visit $30 / visit

Hospice care - inpatient $100 / day (3-day max) $250 / day (3-day max) $200 / day admission $500 / day (3-day max) $500 / day (3-day max) $200 / admission $200 / admission $200 / admission

Hospice care - outpatient $0 $0 $0 $0 $0 $0 $0 $0

2_{Includes preventive services with rating of A or B from the US Preventive Services Task Force; immunizations for children, adolescents and adults recommended by the Centers for Disease Control and Prevention;}

and preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents and women. If preventive care is received at the time of other services, the applicable copayment for such services other than preventive care may apply. 3_{Of contracted rates.}

(6)

Sharp Gold 80

0 / 30 / 30% Sharp Gold 80 0 / 40 / 40% Sharp Gold 80 0 / 30 / 1000 A Sharp Gold 80 0 / 30 / 1000 B Sharp Gold 80 0 / 40 / 1000 Sharp Gold 80 1000 / 30 / 30% Sharp Silver 70 1750 / 40 / 40%

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) None None None None None $1,0005_{/ $2,000}5 _$1,7505_{/ $3,500}5

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) None None None None $150 $150 $150

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $4,5001_{/ $9,000}1 _$4,5001_{/ $9,000}1 _$6,2501_{/ $12,500}1 _$5,0001_{/ $10,000}1 _$5,0001_{/ $10,000}1 _$3,4001_{/ $6,800}1 _$5,7501_{/ $11,500}1

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $30 $40 $30 $30 $40 $30 $40

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $30 $40 $70 $60 $60 $30 $40

Preventive services² $0 $0 $0 $0 $0 $0 $0

Prenatal and postpartum office visits $30 $40 $70 $60 $60 $30 $40

Allergy injections $30 $40 $30 $30 $40 $30 $40

Allergy testing $30 $40 $70 $60 $60 $30 $40

Outpatient Services

Outpatient surgery 30% coinsurance3 _{40% coinsurance}3 _{$600 / procedure} _{$750 / procedure} _{$750 / procedure} _{30% coinsurance}3,4 _{40% coinsurance}3,4

Radiology services (x-rays and diagnostic imaging) $50 $50 $70 $60 $50 $0 $40

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) 30% coinsurance3 _$150 _$175 _$150 _$150 _$100 _$100

Physical, occupational and speech therapy $30 $40 $70 $60 $60 $30 $40

Inpatient 30% coinsurance3 _{40% coinsurance}3 _{$1,000 / admission} _{$1,000 / day} _{$1,000 / day} _{30% coinsurance}3,4 _{40% coinsurance}3,4

Emergency room (waived if admitted for inpatient hospital stay) $100 $100 $200 $200 $200 $1504 _$1504

Urgent care $30 $40 $70 $60 $40 $30 $40

Ambulance Services

Ambulance in connection with hospital admission or emergency services $100 $100 $100 $100 $100 $1004 _$1504

Prescription Drug Coverage

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0 $0 $0 $0

Generic Formulary / Brand Formulary / Non-Formulary medications up to a 30-day supply $15 / $50 / $70 $19 / $35 / $70 $19 / $35 / $70 $19 / $35 $19 / $354 _{/ $70}4 _{$19 / $35}4_{/ $70}4 _{$19 / $35}4_{/ $70}4

Generic Formulary / Brand Formulary / Non-Formulary / Medications up to a 90-day supply by mail order $30 / $100 / $140 $38 / $70 / $140 $38 / $70 / $140 $38 / $70 / $140 $38 / $704_{/ $140}4 _{$38 / $70}4_{/ $140}4 _{$38 / $70}4_{/ $140}4

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 50% coinsurance3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3,4 _{50% coinsurance}3,4

Diabetics supplies 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Prosthetics, orthotics $30 $40 $70 $60 $60 $30 $40

Outpatient $30 / visit $40 / visit $70 / visit $60 / visit $60 / visit $30 / visit $40 / visit

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism $30 / visit $40 / visit $70 / visit $60 / visit $60 / visit $30 / visit4 _{$40 / visit}4

Emergency services for acute drug or alcohol detoxification $100 / visit $100 / visit $200 / visit $200 / visit $200 / visit $150 / visit4 _{$150 / visit}4

Other

Skilled nursing facility services (maximum of 100 days per benefit period) 30% coinsurance3 _{$150 / day} _{$175 / admission} _{$150 / admission} _{$150 / day} _{30% coinsurance}3,4 _{40% coinsurance}3,4

Home health services (maximum of 100 visits per calendar year) $30 / visit $40 / visit $70 / visit $60 / visit $60 / visit $30 / visit4 _{$40 / visit}

Hospice care - inpatient $150 / day $150 / day $150 / admission $150 / admission $150 / day 30% coinsurance3,4 _{40% coinsurance}3,4

Hospice care - outpatient $0 $0 $0 $0 $0 $0 $0

Small group Gold 80 / Silver 70 plans

1_{Copayments and deductibles for supplemental benefits (Assisted Reproductive Technologies, Chiropractic Services, Adult Vision) do not apply to the annual out of pocket maximum.}

2_{Includes preventive services with rating of A or B from the US Preventive Services Task Force; immunizations for children, adolescents and adults recommended by the Centers for Disease Control and Prevention; and}

preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents and women. If preventive care is received at the time of other services, the applicable copayment for such services other than preventive care may apply. 3_{Of contracted rates.}

(7)

Sharp Gold 80

0 / 30 / 30% Sharp Gold 80 0 / 40 / 40% Sharp Gold 80 0 / 30 / 1000 A Sharp Gold 80 0 / 30 / 1000 B Sharp Gold 80 0 / 40 / 1000 Sharp Gold 80 1000 / 30 / 30% Sharp Silver 70 1750 / 40 / 40%

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) None None None None None $1,0005_{/ $2,000}5 _$1,7505_{/ $3,500}5

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) None None None None $150 $150 $150

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $4,5001_{/ $9,000}1 _$4,5001_{/ $9,000}1 _$6,2501_{/ $12,500}1 _$5,0001_{/ $10,000}1 _$5,0001_{/ $10,000}1 _$3,4001_{/ $6,800}1 _$5,7501_{/ $11,500}1

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $30 $40 $30 $30 $40 $30 $40

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $30 $40 $70 $60 $60 $30 $40

Preventive services² $0 $0 $0 $0 $0 $0 $0

Prenatal and postpartum office visits $30 $40 $70 $60 $60 $30 $40

Allergy injections $30 $40 $30 $30 $40 $30 $40

Allergy testing $30 $40 $70 $60 $60 $30 $40

Outpatient Services

Outpatient surgery 30% coinsurance3 _{40% coinsurance}3 _{$600 / procedure} _{$750 / procedure} _{$750 / procedure} _{30% coinsurance}3,4 _{40% coinsurance}3,4

Radiology services (x-rays and diagnostic imaging) $50 $50 $70 $60 $50 $0 $40

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) 30% coinsurance3 _$150 _$175 _$150 _$150 _$100 _$100

Physical, occupational and speech therapy $30 $40 $70 $60 $60 $30 $40

Emergency room (waived if admitted for inpatient hospital stay) $100 $100 $200 $200 $200 $1504 _$1504

Urgent care $30 $40 $70 $60 $40 $30 $40

Ambulance Services

Ambulance in connection with hospital admission or emergency services $100 $100 $100 $100 $100 $1004 _$1504

Prescription Drug Coverage

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0 $0 $0 $0

Generic Formulary / Brand Formulary / Non-Formulary medications up to a 30-day supply $15 / $50 / $70 $19 / $35 / $70 $19 / $35 / $70 $19 / $35 $19 / $354 _{/ $70}4 _{$19 / $35}4_{/ $70}4 _{$19 / $35}4_{/ $70}4

Generic Formulary / Brand Formulary / Non-Formulary / Medications up to a 90-day supply by mail order $30 / $100 / $140 $38 / $70 / $140 $38 / $70 / $140 $38 / $70 / $140 $38 / $704_{/ $140}4 _{$38 / $70}4_{/ $140}4 _{$38 / $70}4_{/ $140}4

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 50% coinsurance3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3 _{50% coinsurance}3,4 _{50% coinsurance}3,4

Diabetics supplies 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Prosthetics, orthotics $30 $40 $70 $60 $60 $30 $40

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism $30 / visit $40 / visit $70 / visit $60 / visit $60 / visit $30 / visit4 _{$40 / visit}4

Emergency services for acute drug or alcohol detoxification $100 / visit $100 / visit $200 / visit $200 / visit $200 / visit $150 / visit4 _{$150 / visit}4

Other

Skilled nursing facility services (maximum of 100 days per benefit period) 30% coinsurance3 _{$150 / day} _{$175 / admission} _{$150 / admission} _{$150 / day} _{30% coinsurance}3,4 _{40% coinsurance}3,4

Home health services (maximum of 100 visits per calendar year) $30 / visit $40 / visit $70 / visit $60 / visit $60 / visit $30 / visit4 _{$40 / visit}

Hospice care - inpatient $150 / day $150 / day $150 / admission $150 / admission $150 / day 30% coinsurance3,4 _{40% coinsurance}3,4

Hospice care - outpatient $0 $0 $0 $0 $0 $0 $0

4_{Deductible applies.}5_{Individuals enrolled in a family plan will reach the annual deductible maximum if the Member meets the individual deductible maximum amount or if any combination of enrolled family}

(8)

Sharp Platinum 90

0 / 20 /10% (Network 2)5 Sharp Platinum 90 _{0 / 20 / 250 (Network 1)}6 Sharp Gold 80 _{0 / 35 / 20% (Network 2)}5 Sharp Gold 80 _{0 / 35 / 600 (Network 1)}6

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) None None None None

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) None None None None

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $4,0001_{/ $8,000}1 _$4,0001_{/ $8,000}1 _$6,2001_{/ $12,400}1 _$6,2001_{/ $12,400}1

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $20 $20 $35 $35

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $40 $40 $55 $55

Preventive services² $0 $0 $0 $0

Prenatal and postpartum office visits $0 $0 $0 $0

Allergy injections $20 $20 $35 $35

Allergy testing $40 $40 $55 $55

Outpatient Services

Outpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per procedure / $40 per visit} _{20% coinsurance}3_{/ 20% coinsurance}3 _{$600 per procedure / $55}

Radiology services (x-rays and diagnostic imaging) $40 / visit $40 / visit $50 / visit $50 / visit

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) 10% coinsurance3 _{$150 / procedure} _{20% coinsurance}3 _{$250 / procedure}

Physical, occupational and speech therapy $20 / visit $20 / visit $35 / visit $35 / visit

Inpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per day (5-day max) / $40} _{20% coinsurance}3_{/ 20% coninsurance}3 _{$600 per day (5-day max) / $55 per visit}

Emergency room facility / physician (waived if admitted for inpatient hospital stay) $150 per visit / 10% coinsurance3 _{$150 per visit / $0} _{$250 per visit / 20%}3 _{$250 per visit / $0}

Urgent care $40 $40 $60 $60

Ambulance Services

Ambulance in connection with hospital admission or emergency services $150 $150 $250 $250

Prescription Drug Coverage

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0

Tier 1 / Tier 2 / Tier 3 / Tier 4 medications up to a 30-day supply $5 / $15 / $25 / 10%4 _{$5 / $15 / $25 / 10%}4 _{$15 / $50 / $70 / 20%} 4 _{$15 / $50 / $70 / 20%} 4

Tier 1 / Tier 2 / Tier 3 medications up to a 90-day supply by mail order $10 / $30 / $50 $10 / $30 / $50 $30 / $100 / $140 $30 / $100 / $140

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 10% coinsurance3 _{10% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Diabetics supplies 10% coinsurance3 _{10% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Prosthetics, orthotics 10% coinsurance3 _{10% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Inpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per day (5-day max) / $40 per visit} _{20% coinsurance}3_{/ 20% coinsurance}3 _{$600 per day (5-day max) / $55 per visit}

Outpatient $20 / visit $20 / visit $35 / visit $35 / visit

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism $20 / visit $20 / visit 20% coinsurance3 _{$30 / visit}

Chemical Dependency Services

Inpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per day (5-day max) / $40 per visit} _{20% coinsurance}3_{/20% coinsurance}3 _{$600 per day (5-day max) / $55 per visit}

Emergency services for acute drug or alcohol detoxification inpatient facility / physician $150 per visit / $0 $150 per visit / $0 20% coinsurance3_{/ 20% coinsurance}3 _{$250 per visit / $0}

Other

Skilled nursing facility services (maximum of 100 days per benefit period) 10% coinsurance3 _{$150 / day (5-day max)} _{20% coinsurance}3 _{$300 / day (5-day max)}

Home health services (maximum of 100 visits per calendar year) 10% coinsurance3 _{$20 / visit} _{20% coinsurance}3 _{$30 / visit}

Hospice care - inpatient $0 / admission $0 / admission $0 / admission $0 / admission

Hospice care - outpatient $0 $0 $0 $0

Covered CA Platinum 90 / Gold 80 plans

preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents and women. If preventive care is received at the time of other services, the applicable copayment for such services other than preventive care may apply.

(9)

Sharp Platinum 90

0 / 20 /10% (Network 2)5 Sharp Platinum 90 _{0 / 20 / 250 (Network 1)}6 Sharp Gold 80 _{0 / 35 / 20% (Network 2)}5 Sharp Gold 80 _{0 / 35 / 600 (Network 1)}6

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) None None None None

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) None None None None

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $4,0001_{/ $8,000}1 _$4,0001_{/ $8,000}1 _$6,2001_{/ $12,400}1 _$6,2001_{/ $12,400}1

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $20 $20 $35 $35

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $40 $40 $55 $55

Preventive services² $0 $0 $0 $0

Prenatal and postpartum office visits $0 $0 $0 $0

Allergy injections $20 $20 $35 $35

Allergy testing $40 $40 $55 $55

Outpatient Services

Outpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per procedure / $40 per visit} _{20% coinsurance}3_{/ 20% coinsurance}3 _{$600 per procedure / $55}

Radiology services (x-rays and diagnostic imaging) $40 / visit $40 / visit $50 / visit $50 / visit

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) 10% coinsurance3 _{$150 / procedure} _{20% coinsurance}3 _{$250 / procedure}

Physical, occupational and speech therapy $20 / visit $20 / visit $35 / visit $35 / visit

Inpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per day (5-day max) / $40} _{20% coinsurance}3_{/ 20% coninsurance}3 _{$600 per day (5-day max) / $55 per visit}

Emergency room facility / physician (waived if admitted for inpatient hospital stay) $150 per visit / 10% coinsurance3 _{$150 per visit / $0} _{$250 per visit / 20%}3 _{$250 per visit / $0}

Urgent care $40 $40 $60 $60

Ambulance Services

Ambulance in connection with hospital admission or emergency services $150 $150 $250 $250

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0

Tier 1 / Tier 2 / Tier 3 / Tier 4 medications up to a 30-day supply $5 / $15 / $25 / 10%4 _{$5 / $15 / $25 / 10%}4 _{$15 / $50 / $70 / 20%} 4 _{$15 / $50 / $70 / 20%} 4

Tier 1 / Tier 2 / Tier 3 medications up to a 90-day supply by mail order $10 / $30 / $50 $10 / $30 / $50 $30 / $100 / $140 $30 / $100 / $140

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 10% coinsurance3 _{10% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Diabetics supplies 10% coinsurance3 _{10% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Prosthetics, orthotics 10% coinsurance3 _{10% coinsurance}3 _{20% coinsurance}3 _{20% coinsurance}3

Inpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per day (5-day max) / $40 per visit} _{20% coinsurance}3_{/ 20% coinsurance}3 _{$600 per day (5-day max) / $55 per visit}

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism $20 / visit $20 / visit 20% coinsurance3 _{$30 / visit}

Chemical Dependency Services

Inpatient facility / physician 10% coinsurance3_{/10% coinsurance}3 _{$250 per day (5-day max) / $40 per visit} _{20% coinsurance}3_{/20% coinsurance}3 _{$600 per day (5-day max) / $55 per visit}

Emergency services for acute drug or alcohol detoxification inpatient facility / physician $150 per visit / $0 $150 per visit / $0 20% coinsurance3_{/ 20% coinsurance}3 _{$250 per visit / $0}

Other

Skilled nursing facility services (maximum of 100 days per benefit period) 10% coinsurance3 _{$150 / day (5-day max)} _{20% coinsurance}3 _{$300 / day (5-day max)}

Home health services (maximum of 100 visits per calendar year) 10% coinsurance3 _{$20 / visit} _{20% coinsurance}3 _{$30 / visit}

Hospice care - inpatient $0 / admission $0 / admission $0 / admission $0 / admission

Hospice care - outpatient $0 $0 $0 $0

3_{Of contracted rates.} 4_{Up to $250 per 30-day supply.} 5_{Network 2 is the Performance Network.} 6_{Network 1 is the Premier Network.}

(10)

Sharp Silver 70 1500 / 45 / 20% A (Network 2)10 Sharp Silver 70 1500 / 45 / 20% B (Network 1)11

Sharp Silver 70 HSA 2000 / 20% / 20% (Network 1)11

Sharp Bronze 60 6000 / 70 / 100% (Network 2)10

Sharp Bronze 60 HSA 4500 / 40% / 40% (Network 1)11

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) $1,5006_{/ $3,000}6 _$1,5006_{/ $3,000}6 _$2,0004_{/ $4,000}4_Integrated _$6,0006_{/ $12,000}6_Integrated _$4,5004_{/ $9,000}4_Integrated

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) $250 / $500 $250 / $500 Integrated $500 / $1,000 Integrated

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $6,5001_{/ $13,000}1 _$6,5001_{/ $13,000}1 _$6,2501_{/ $12,500}1 _$6,5001_{/ $13,000}1 _$6,5001_{/ $13,000}1

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $45 $45 20% coinsurance3,5 _$705,7 _{40% coinsurance}3,5

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $70 $70 20% coinsurance3,5 _$905,7 _{40% coinsurance}3,5

Preventive services² $0 $0 $0 $0 $0

Prenatal and postpartum office visits $0 $0 $0 $0 $0

Allergy injections $45 $45 20% coinsurance3,5 _$705 _{40% coinsurance}3,5

Allergy testing $70 $70 20% coinsurance3,5 _$905 _{40% coinsurance}3,5

Outpatient Services

Outpatient facility / physician 20% coinsurance3_{/ 20% coinsurance}3 _{20% coinsurance}3_{/ 20% coinsurance}3 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{100% coinsurance}3,5_{/ 100% coinsurance}3,5 _{40% coinsurance}3,5_{/ 40% coinsurance}3,5

Radiology services (x-rays and diagnostic imaging) $65 / visit $65 / visit 20% coinsurance3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) 20% coinsurance3,5 _{$250 / procedure} _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Physical, occupational and speech therapy $45 / visit $45 / visit 20% coinsurance3,5 _{$70 / visit}5 _{40% coinsurance}3,5

Inpatient facility / physician 20% coinsurance3,5_{/ 20% coinsurance}3,5 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{100% coinsurance}3,5_{/ 100% coinsurance}3,5 _{40% coinsurance}3,5_{/ 40% coinsurance}3,5

Emergency room facility / physician (waived if admitted for inpatient hospital stay) $250 per visit5_{/ $50 per visit}5 _{$250 per visit}5_{/ $50 per visit}5 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{100% coinsurance}3,5_{/ 100% coinsurance}3,5 _{40% coinsurance}3,5_{/ 40% coinsurance}3,5

Urgent care $90 $90 20% coinsurance3,5 _$1205,7 _{40% coinsurance}3,5

Ambulance Services

Ambulance in connection with hospital admission or emergency services $2505 _$2505 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

(suggested coverage; other supplemental drug coverage available)

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0 $0

Tier 1 / Tier 2 / Tier 3 / Tier 4 medications up to a 30-day supply $15 / $555_{/ $75}5_{/ 20%}5,8 _{$15 / $55}5_{/ $75}5_{/ 20%}5,8 _20%5_{/ 20%}5_{/ 20%}5_{/ 20%}5 _100%5,9_{/ 100%}5,9_{/ 100%}5,9_{/ 100%}5,9 _40%5_{/ 40%}5_{/ 40%}5_{/ 40%}5

Tier 1 / Tier 2 / Tier 3 medications up to a 90-day supply by mail order $30 / $1105_{/ $150}5 _{$30 / $110}5_{/ $150}5 _20%5_{/ 20%}5_{/ 20%}5 _100%5,9_{/ 100%}5,9_{/ 100%}5,9 _40%5_{/ 40%}5_{/ 40%}5

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Diabetics supplies 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Prosthetics, orthotics 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Outpatient $45 / visit $45 / visit 20% coinsurance3,5 _{$70 / visit}5,7 _{40% coinsurance}3,5

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism 20% coinsurance3 _{$45 / visit} _{20% coinsurance}3,5 _{$70 / visit}5 _{40% coinsurance}3,5

Chemical Dependency Services

Emergency services for acute drug or alcohol detoxification inpatient facility / physician $250 per visit5 _{/ $50 per visit}5 _{$250 per visit}5_{/ $50 per visit}5 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{100% coinsurance}3,5_{/ 100% coinsurance}3,5 _{40% coinsurance}3,5_{/ 40% coinsurance}3,5

Other

Skilled nursing facility services (maximum of 100 days per benefit period) 20% coinsurance3,5 _{20% coinsurance}3,5 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Home health services (maximum of 100 visits per calendar year) 20% coinsurance3 _{$45 / visit} _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Hospice care - inpatient $0 / admission $0 / admission $0 / admission5 _{$0 / admission} _{$0 / admission}5

Hospice care - outpatient $0 $0 $05 _$0 _$0

Covered CA Silver 70 / Bronze 60 plans

preventive care and screenings supported by the Health Resources and Services Administration for infants, children, adolescents and women. If preventive care is received at the time of other services, the applicable copayment for such services other than preventive care may apply.

(11)

Sharp Silver 70 1500 / 45 / 20% A (Network 2)10 Sharp Silver 70 1500 / 45 / 20% B (Network 1)11

Sharp Silver 70 HSA 2000 / 20% / 20% (Network 1)11

Sharp Bronze 60 6000 / 70 / 100% (Network 2)10

Sharp Bronze 60 HSA 4500 / 40% / 40% (Network 1)11

Deductibles

Calendar year deductible (per individual/per family) (applies only to those covered benefits indicated) $1,5006_{/ $3,000}6 _$1,5006_{/ $3,000}6 _$2,0004_{/ $4,000}4_Integrated _$6,0006_{/ $12,000}6_Integrated _$4,5004_{/ $9,000}4_Integrated

Calendar year deductible (per member) for covered brand-name drugs (formulary and non-formulary) $250 / $500 $250 / $500 Integrated $500 / $1,000 Integrated

Maximums

There are no lifetime maximums for this plan N / A N / A N / A N / A N / A

Annual Out of Pocket Maximum, including deductible (per individual/per family) $6,5001_{/ $13,000}1 _$6,5001_{/ $13,000}1 _$6,2501_{/ $12,500}1 _$6,5001_{/ $13,000}1 _$6,5001_{/ $13,000}1

(per visit)

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $45 $45 20% coinsurance3,5 _$705,7 _{40% coinsurance}3,5

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $70 $70 20% coinsurance3,5 _$905,7 _{40% coinsurance}3,5

Preventive services² $0 $0 $0 $0 $0

Prenatal and postpartum office visits $0 $0 $0 $0 $0

Allergy injections $45 $45 20% coinsurance3,5 _$705 _{40% coinsurance}3,5

Allergy testing $70 $70 20% coinsurance3,5 _$905 _{40% coinsurance}3,5

Outpatient Services

Outpatient facility / physician 20% coinsurance3_{/ 20% coinsurance}3 _{20% coinsurance}3_{/ 20% coinsurance}3 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{100% coinsurance}3,5_{/ 100% coinsurance}3,5 _{40% coinsurance}3,5_{/ 40% coinsurance}3,5

Radiology services (x-rays and diagnostic imaging) $65 / visit $65 / visit 20% coinsurance3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Advanced radiology (including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT) 20% coinsurance3,5 _{$250 / procedure} _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Physical, occupational and speech therapy $45 / visit $45 / visit 20% coinsurance3,5 _{$70 / visit}5 _{40% coinsurance}3,5

Emergency room facility / physician (waived if admitted for inpatient hospital stay) $250 per visit5_{/ $50 per visit}5 _{$250 per visit}5_{/ $50 per visit}5 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{100% coinsurance}3,5_{/ 100% coinsurance}3,5 _{40% coinsurance}3,5_{/ 40% coinsurance}3,5

Urgent care $90 $90 20% coinsurance3,5 _$1205,7 _{40% coinsurance}3,5

Ambulance Services

Ambulance in connection with hospital admission or emergency services $2505 _$2505 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

(suggested coverage; other supplemental drug coverage available)

Drugs administered in a practitioner’s office, hospital or outpatient facility $0 $0 $0 $0 $0

Tier 1 / Tier 2 / Tier 3 / Tier 4 medications up to a 30-day supply $15 / $555_{/ $75}5_{/ 20%}5,8 _{$15 / $55}5_{/ $75}5_{/ 20%}5,8 _20%5_{/ 20%}5_{/ 20%}5_{/ 20%}5 _100%5,9_{/ 100%}5,9_{/ 100%}5,9_{/ 100%}5,9 _40%5_{/ 40%}5_{/ 40%}5_{/ 40%}5

Tier 1 / Tier 2 / Tier 3 medications up to a 90-day supply by mail order $30 / $1105_{/ $150}5 _{$30 / $110}5_{/ $150}5 _20%5_{/ 20%}5_{/ 20%}5 _100%5,9_{/ 100%}5,9_{/ 100%}5,9 _40%5_{/ 40%}5_{/ 40%}5

Generic Formulary and prescribed over-the-counter contraceptives for women $0 $0 $0 $0 $0

Durable Medical Equipment

Durable medical equipment 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Diabetics supplies 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Prosthetics, orthotics 20% coinsurance3 _{20% coinsurance}3 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism 20% coinsurance3 _{$45 / visit} _{20% coinsurance}3,5 _{$70 / visit}5 _{40% coinsurance}3,5

Chemical Dependency Services

Emergency services for acute drug or alcohol detoxification inpatient facility / physician $250 per visit5 _{/ $50 per visit}5 _{$250 per visit}5_{/ $50 per visit}5 _{20% coinsurance}3,5_{/ 20% coinsurance}3,5 _{100% coinsurance}3,5_{/ 100% coinsurance}3,5 _{40% coinsurance}3,5_{/ 40% coinsurance}3,5

Other

Skilled nursing facility services (maximum of 100 days per benefit period) 20% coinsurance3,5 _{20% coinsurance}3,5 _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Home health services (maximum of 100 visits per calendar year) 20% coinsurance3 _{$45 / visit} _{20% coinsurance}3,5 _{100% coinsurance}3,5 _{40% coinsurance}3,5

Hospice care - inpatient $0 / admission $0 / admission $0 / admission5 _{$0 / admission} _{$0 / admission}5

Hospice care - outpatient $0 $0 $05 _$0 _$0

3_{Of contracted rates.}4_{In high-deductible health plans (HDHPs) linked to Health Savings Accounts (HSAs), each individual in a family plan must meet an amount of either $2,600 or the individual deductible,}

whichever is higher, until the family deductible is met. 5_{Deductible applies.}6_{Individuals enrolled in a family plan will reach the annual deductible maximum if the Member meets the individual deductible maximum}

amount or if any combination of enrolled family members meets the family deductible maximum amount, whichever comes first. 7_{Deductible applies after the first three non-preventive visits.}

(12)

163 15 94 94 94 125 125 67 67 67 54 78 56 52 52 76 76 78 78 78 78 86 111 79 79 79 79 74 74 2 163 15 94 94 94 125 125 67 67 67 54 78 56 52 52 76 76 78 78 78 78 86 111 79 79 74 74 2 SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS Alpine Poway Santee La Jolla Del Mar Solana Beach Rancho Santa Fe San Marcos Vista Mira Costa North Valley Ocean Hills Twin Oaks Valley View Rosemont Ramona Julian Encinitas Carlsbad Escondido Valley Center Oceanside Leucadia Mira Mesa Miramar North City

Del Mar Heights

Sabre Springs Rancho Bernardo Carmel Mountain San Diego County Estates El Cajon La Mesa Coronado (Imperial Beach) (San Ysidro) Eastlake Vistas Jamacha Jamul (Otay Mesa)

National City Bonita

Rolling Hills Ranch Chula Vista Lemon Grove Encanto Grossmont Crest Lakeside Linda Vista Mission Valley Ocean Beach University Heights

Loma Portal Spring

Valley

H

2

1

3

9

H

6

H

11

H

4 5

10

H

7

H

8

Tri-City

Art C

Copayments equal to 50% coinsurance of covered infertility services

Assisted Reproductive Technologies (ART)

For employers with 20+ employees

Advantage

$10 per visit / Eye exam: 1 every 12 months / Frames: 1 every 24 months / Lenses: 1 every 12 months

Vision services

Vision Service Plan (VSP)

Supplemental benefits available with every plan

All plans include pediatric vision and dental benefits for members up to age 19. A portfolio of dental HMO and PPO plans,

provided through Premier Access Dental, is also available.

AC23

$15 per visit / 20 visits per year

AC21

AC19

Acupuncture services

American Specialty Health (ASH) Plans

AC17

AC15

AC13

AC33

AC31

$15 per visit / 15 visits per year

AC29

AC27

Chiropractic + Acupuncture services

AC25

AC04

AC03

AC02

AC34

$5 per visit / 40 visits per year

B

Chiropractic services

(13)

163 15 94 94 94 125 125 67 67 67 54 78 56 52 52 76 76 78 78 78 78 86 111 79 79 79 79 74 74 2 163 15 94 94 94 125 125 67 67 67 54 78 56 52 52 76 76 78 78 78 78 86 111 79 79 74 74 2 SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS SRS Alpine Poway Santee La Jolla Del Mar Solana Beach Rancho Santa Fe San Marcos Vista Mira Costa North Valley Ocean Hills Twin Oaks Valley View Rosemont Ramona Julian Encinitas Carlsbad Escondido Valley Center Oceanside Leucadia Mira Mesa Miramar North City

Del Mar Heights

Sabre Springs Rancho Bernardo Carmel Mountain San Diego County Estates El Cajon La Mesa Coronado (Imperial Beach) (San Ysidro) Eastlake Vistas Jamacha Jamul (Otay Mesa)

National City Bonita

Rolling Hills Ranch Chula Vista Lemon Grove Encanto Grossmont Crest Lakeside Linda Vista Mission Valley Ocean Beach University Heights

Loma Portal Spring

Valley

H

2

1

3

9

H

6

H

11

H

4 5

10

H

7

H

8

Tri-City

Provider Networks

Sharp Health Plan offers four provider networks

for flexibility while delivering high-quality health

services: Choice, Value, Performance and Premier.

13 Hospitals

2,200+ Doctors

(14)

Physician Networks

Sharp Rees-Stealy (SRS)

Carmel Valley

Chula Vista

Del Mar

Downtown San Diego

El Cajon

Frost Street

Genesee

Kearny Villa

La Mesa/La Mesa West

Mira Mesa

Mt. Helix

Otay Ranch

Point Loma

Rancho Bernardo

San Carlos

San Diego

Scripps Ranch

Sorrento Mesa

Sharp Community Medical Group (SCMG)

Alpine

Chula Vista

Clairemont

Coronado

Downtown San Diego

East San Diego

El Cajon

Imperial Beach

SCMG Continued

Kearny Mesa

La Mesa

Lakeside

Mira Mesa

National City

Point Loma

San Carlos

Santee

Tierrasanta

University City

Sharp Community Medical Group (SCMG) Inland North

Escondido

Poway

SCMG Graybill

Carlsbad

Escondido

Fallbrook

Oceanside

San Marcos

Temecula

Vista

SCMG Arch Health Partners

Escondido

Poway

Ramona

San Marcos

1 _{Coverage area includes but is not limited to the locations in this document. Premier is a preferred premium rate provider network and is available in select ZIP codes throughout San Diego County.}

To see if your business qualifies for this provider network, please contact your Sharp Health Plan Account Manager.

Provider Network Comparison

At Sharp Health Plan, we offer four provider networks to deliver cost-effective solutions to meet the unique needs of every

employer. With access to more than 2,240 Physicians, we have an option that’s right for you.

1

Network 1 - Premier

Network 2 - Performance

Network 3 - Value

Network 4 - Choice

A high-performing,

select network and our

most affordable option.

An affordable network in

San Diego County offering

more choice for people living

in the North County area.

A large network of

medical professionals devoted

to giving you the best possible

care and value.

Our largest network,

offering the most choice

(15)

Participating physicians are subject to change;

for the most current information, please visit

sharphealthplan.com.

Children’s Physicians Medical Group

Carlsbad

Chula Vista

Clairemont

Del Mar

Downtown San Diego

Eastlake

East San Diego

El

Cajon

Encinitas

Escondido

Fallbrook

Hillcrest

La Jolla

La Mesa

Linda Vista

Mira Mesa

National City

Oceanside

Poway

Pt. Loma

Rancho Bernardo

San Marcos

Scripps Ranch

Sorrento Valley

Temecula

University City

Valley Center

Vista

Greater Tri-Cities IPA

Carlsbad

Oceanside

Vista

Primary Care Associates Medical Group

Carlsbad

Encinitas

Oceanside

San Marcos

Solana Beach

Vista

Independent Physician Network

More than 227 Primary Care

Providers and 435 Specialists

are independently contracted.

Sharp Chula Vista

Medical Center

Sharp Coronado Hospital

Sharp Grossmont Hospital

Sharp Mary Birch Hospital for

Women & Newborns

Sharp Memorial Hospital

Sharp Mesa Vista Hospital

Palomar Downtown

Palomar Medical Center

Pomerado Hospital

Rady Children’s Hospital

Tri-City Medical Center

Inland Valley Medical Center

Rancho Springs Medical Center

Albertsons Sav-on Pharmacy

™

Costco

®

Pharmacy

CVS/pharmacy

®

Independent Neighborhood

Pharmacies

Ralphs

®

Pharmacy

Rite Aid

®

Pharmacy

Sharp Rees-Stealy Pharmacy

Target

®

Pharmacy

Vons

®

Pharmacy

Walgreens

®

Pharmacy

Walmart

®

Pharmacy

Wellpartner

®

(Mail order pharmacy)

Hospital Networks

(16)

Consider us your personal

health care assistant

(858) 499-8300 or 1-800-359-2002

8 a.m. – 6 p.m., Monday through Friday

[email protected]

sharphealthplan.com