Large group benefit comparison

A guide to choosing the right plan for your business

effective January 1, 2015

Large group

benefit comparison

effective January 1, 2015

With a range of plans and provider networks,

we have the right plan to meet your unique business needs.

Sharp Health Plan is your first choice in San Diego

for access to high-quality, affordable health care

for a healthy workforce.

San Diegans choose

Sharp Health Plan

Customizable

With four provider networks, a

multitude of plan designs and a broad

range of pricing options, you have the

ability to tailor your plan design to

your business needs.

Local focus

As the only San Diego-based

commercial health plan, all of

our services, from account

management to customer care,

are provided locally.

Award-winning care

You’ll receive award-winning care

from our nationally recognized

doctors, medical groups

and hospitals.

We’re proud to be a top 100 US health plan

1

At Sharp Health Plan, we believe in making life better. We are honored to be one of the best health plans in the nation.

¹ Based on NCQA’s Private Health Insurance Rankings 2014-2015. ² Based on the 2014 California Assessment of Healthcare Providers and Systems (CAHPS®_{) results, Sharp Health Plan received an} overall summary rating of 86% satisfaction compared to the statewide average of 76%. For customer service, Sharp Health Plan received a 90% satisfaction rating and the statewide average was not reported. The source for data contained in this publication is Quality Compass® _{2014 and is used with the permission of the National Committee for Quality Assurance (NCQA).}

Quality Compass® _{2014 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).

Highest-level

“Excellent” Accreditation

Highest level “Excellent”

Accreditation

4 out of 4-star quality rating

Highest rated customer

service and member satisfaction

2

Top 100 US health plan

1

100

_TOP

among reporting California health plans3

Highest level “Excellent” Accreditation

4 out of 4-star quality rating Top 100

US health plan1

Highest rated customer

service and member satisfaction2

100

TOP

Highest level “Excellent”

Accreditation 4 out of 4-star quality rating Top 100

US health plan1 Highest rated _{customer service and}

member satisfaction2

among reporting California health plans3

100

TOP

4 out of 4-star

quality rating

100

US health plan† TO P

Top 100 US health plan

1

Highest-rated

customer service and

member satisfaction

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 beyond standard business hours. All Sharp Health Plan

members receive the following value-added benefits:

Best Health is one of only twelve health plan wellness programs to be accredited nationally. 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.

Sharp Nurse Connection’s specially trained registered nurses can talk with you about your illness or injury, help you decide where to seek care and provide advice on any health concerns you may have.

Sharp Nurse Connection

Get care for minor illnesses, injuries and more through MinuteClinic®, the medical clinic in select CVS/pharmacy stores® in San Diego and across the nation.1

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.

®

1 _{A $40 copay will apply to most services except flu shots, which have a copay of $10.}

Service

Plan

Copayment (per visit)

Visits (per year)

Acupuncture

American Specialty Health (ASH)

AC12 $10 12 AC14 $10 15 AC16 $10 20 AC18 $15 12 AC20 $15 15 AC22 $15 20 Chiropractic

American Specialty Health (ASH)

AC10 $15 20 AC11 $15 30 B-LG $10 30 D-LG $10 20 Chiropractic and Acupuncture

American Specialty Health (ASH)

AC2 $5 40 AC3 $10 40 AC4 $10 20 AC24 $10 12 AC26 $10 15 AC28 $10 12 AC30 $15 15 AC32 $15 20 Vision

Vision Service Plan (VSP)

A0 $0 _{Frames/lenses: discount based on retail costs}Eye exam: 1 every 12 months

A2 $20 Eye exam: 1 every 12 months _{Frames/lenses: $20}

A8 $30 _{Frames/lenses: discount based on retail costs}Eye exam: 1 every 24 months

OC $0 Eye exam: 1 every 12 months _{Frames/lenses: $0} Assisted Reproductive

Technologies (ART)

ART A 50% coinsurance* n/a ART B 50% coinsurance* n/a ART C 50% coinsurance* n/a

Provider networks

Sharp Health Plan offers four provider networks to provide flexibility

while delivering high-quality, affordable health services: Choice, Value, Performance and Premier.

Plans listed do not represent our entire plan portfolio. 1 _{For non-HSA plans, individuals enrolled in a family plan will reach the annual deductible and/or out-of-pocket maximum amount} if the member meets the individual maximum amount or any combination of enrolled family members meets the family deductible and/or out-of-pocket maximum, whichever comes first. HSA plans are accumulated differently.

Sharp Health Plan benefit comparison

10 / 10 / 100

Sharp

15 / 15 / 0

Sharp

15 / 15 / 250

Sharp

20 / 20 / 250

Sharp

20 / 40 / 500

Sharp

25 / 25 / 500

Sharp

25 / 35 / 500

Sharp

(3-day max)

Sharp

30 / 40 / 500 day

40 / 40 / 40%

Sharp

40 / 50 / 750

Sharp

(3-day max)

Sharp

1000 ded / 30 / 40

1500 ded / 30 / 30

Sharp HSA

1500 ded / 40 / 40

Sharp

2500 ded / 40 / 40

Sharp

3000 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 50

Sharp

Calendar year deductible (per individual / per family, applies only to those covered benefits indicated)1 _{None None None None None None None None None None $1,000 / $2,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $4,500 / $9,000 $4,500 / $9,000}

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 n/a 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) 1, 2 _{$1,500 / $3,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $3,000 / $6,000 $3,500 / $7,000 $3,500 / $7,000 $4,000 / $8,000 $3,500 / $7,000 $3,500 / $7,000 $3,000 / $6,000 $4,000 / $8,000 $5,000 / $10,000 $6,000 / $12,000 $6,350 / $12,700 $6,000 / $12,000}

Professional

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $20 $25 $25 $30 $40 $40 $30 $30 6 _{$40 $40 $40} 6 _$40 6 _$40

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Preventive care services (per visit)3 _{$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0}

Prenatal and postpartum office visits (per visit) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Allergy injections (per visit) $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $30 6 _{$10 $10 $40} 6 _$40 6 _$10

Allergy testing (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Outpatient

Outpatient surgery (per procedure) $0 $0 $125 $125 $250 $250 $500 $500 40% coinsurance 4 _{$750 30% coinsurance} 4,6 _$150 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Laboratory services $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $10 6 _{$0 $0 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$0

Advanced radiology including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT (per procedure) $0 $0 $100 $100 $100 $100 $100 $100 $100 $100 $100 $50 6 _{$100 $100 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$100

Physical, occupational and speech therapy (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Hospitalization

Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Emergency / Urgent Care

Emergency room (per visit, waived if admitted for inpatient hospital stay) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150

6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

Urgent care (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $40 6 _{$40 $40 $50} 6 _$50 6 _$50

Ambulance

Ambulance in connection with hospital admission or emergency services $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _$100 6 _$100 6 _$200 6

Durable Medical Equipment

Durable medical equipment 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6

Diabetic supplies 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4,6 _{20% coinsurance} 4

Prosthetics, orthotics (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Mental Health

5 Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance

4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40} 6 _$40 6 _{$40 $50}

Chemical Dependency

Inpatient

(per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Emergency services for acute drug or alcohol detoxification (per visit) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

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

Sharp Health Plan benefit comparison

10 / 10 / 100

Sharp

15 / 15 / 0

Sharp

15 / 15 / 250

Sharp

20 / 20 / 250

Sharp

20 / 40 / 500

Sharp

25 / 25 / 500

Sharp

25 / 35 / 500

Sharp

(3-day max)

Sharp

30 / 40 / 500 day

40 / 40 / 40%

Sharp

40 / 50 / 750

Sharp

(3-day max)

Sharp

1000 ded / 30 / 40

1500 ded / 30 / 30

Sharp HSA

1500 ded / 40 / 40

Sharp

2500 ded / 40 / 40

Sharp

3000 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 50

Sharp

Calendar year deductible (per individual / per family, applies only to those covered benefits indicated)1 _{None None None None None None None None None None $1,000 / $2,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $4,500 / $9,000 $4,500 / $9,000}

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 n/a 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) 1, 2 _{$1,500 / $3,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $3,000 / $6,000 $3,500 / $7,000 $3,500 / $7,000 $4,000 / $8,000 $3,500 / $7,000 $3,500 / $7,000 $3,000 / $6,000 $4,000 / $8,000 $5,000 / $10,000 $6,000 / $12,000 $6,350 / $12,700 $6,000 / $12,000}

Professional

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $20 $25 $25 $30 $40 $40 $30 $30 6 _{$40 $40 $40} 6 _$40 6 _$40

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Preventive care services (per visit)3 _{$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0}

Prenatal and postpartum office visits (per visit) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Allergy injections (per visit) $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $30 6 _{$10 $10 $40} 6 _$40 6 _$10

Allergy testing (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Outpatient

Outpatient surgery (per procedure) $0 $0 $125 $125 $250 $250 $500 $500 40% coinsurance 4 _{$750 30% coinsurance} 4,6 _$150 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Laboratory services $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $10 6 _{$0 $0 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$0

Advanced radiology including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT (per procedure) $0 $0 $100 $100 $100 $100 $100 $100 $100 $100 $100 $50 6 _{$100 $100 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$100

Physical, occupational and speech therapy (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Hospitalization

Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Emergency / Urgent Care

Emergency room (per visit, waived if admitted for inpatient hospital stay) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150

6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

Urgent care (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $40 6 _{$40 $40 $50} 6 _$50 6 _$50

Ambulance

Ambulance in connection with hospital admission or emergency services $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _$100 6 _$100 6 _$200 6

Durable Medical Equipment

Durable medical equipment 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6

Diabetic supplies 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4,6 _{20% coinsurance} 4

Prosthetics, orthotics (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Mental Health

5 Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance

4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40} 6 _$40 6 _{$40 $50}

Chemical Dependency

Inpatient

(per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Emergency services for acute drug or alcohol detoxification (per visit) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

2 _{Copayments for supplemental benefits (Assisted Reproductive Technologies, Acupuncture, Chiropractic Services and Vision) do not apply to the annual out-of-pocket maximum.} 3 _{Includes preventive services with a rating of A or B from the US Preventive Services Task Force; immunizations for children, adolescents and adults recommended by the} Centers of 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.

Sharp Health Plan benefit comparison

10 / 10 / 100

Sharp

15 / 15 / 0

Sharp

15 / 15 / 250

Sharp

20 / 20 / 250

Sharp

20 / 40 / 500

Sharp

25 / 25 / 500

Sharp

25 / 35 / 500

Sharp

(3-day max)

Sharp

30 / 40 / 500 day

40 / 40 / 40%

Sharp

40 / 50 / 750

Sharp

(3-day max)

Sharp

1000 ded / 30 / 40

1500 ded / 30 / 30

Sharp HSA

1500 ded / 40 / 40

Sharp

2500 ded / 40 / 40

Sharp

3000 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 50

Sharp

Calendar year deductible (per individual / per family, applies only to those covered benefits indicated)1 _{None None None None None None None None None None $1,000 / $2,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $4,500 / $9,000 $4,500 / $9,000}

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 n/a 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) 1, 2 _{$1,500 / $3,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $3,000 / $6,000 $3,500 / $7,000 $3,500 / $7,000 $4,000 / $8,000 $3,500 / $7,000 $3,500 / $7,000 $3,000 / $6,000 $4,000 / $8,000 $5,000 / $10,000 $6,000 / $12,000 $6,350 / $12,700 $6,000 / $12,000}

Professional

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $20 $25 $25 $30 $40 $40 $30 $30 6 _{$40 $40 $40} 6 _$40 6 _$40

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Preventive care services (per visit)3 _{$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0}

Prenatal and postpartum office visits (per visit) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Allergy injections (per visit) $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $30 6 _{$10 $10 $40} 6 _$40 6 _$10

Allergy testing (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Outpatient

Outpatient surgery (per procedure) $0 $0 $125 $125 $250 $250 $500 $500 40% coinsurance 4 _{$750 30% coinsurance} 4,6 _$150 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Laboratory services $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $10 6 _{$0 $0 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$0

Advanced radiology including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT (per procedure) $0 $0 $100 $100 $100 $100 $100 $100 $100 $100 $100 $50 6 _{$100 $100 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$100

Physical, occupational and speech therapy (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Hospitalization

Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Emergency / Urgent Care

Emergency room (per visit, waived if admitted for inpatient hospital stay) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150

6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

Urgent care (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $40 6 _{$40 $40 $50} 6 _$50 6 _$50

Ambulance

Ambulance in connection with hospital admission or emergency services $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _$100 6 _$100 6 _$200 6

Durable Medical Equipment

Durable medical equipment 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6

Diabetic supplies 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4,6 _{20% coinsurance} 4

Prosthetics, orthotics (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Mental Health

5 Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance

4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40} 6 _$40 6 _{$40 $50}

Chemical Dependency

Inpatient

(per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Emergency services for acute drug or alcohol detoxification (per visit) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

4 _{Of contracted rates.}

5 _{Coverage for the diagnosis and treatment of Severe Mental Illnesses in members of any age and Serious Emotional Disturbances in children.} 6 _{Deductible applies.}

Sharp Health Plan benefit comparison

10 / 10 / 100

Sharp

15 / 15 / 0

Sharp

15 / 15 / 250

Sharp

20 / 20 / 250

Sharp

20 / 40 / 500

Sharp

25 / 25 / 500

Sharp

25 / 35 / 500

Sharp

(3-day max)

Sharp

30 / 40 / 500 day

40 / 40 / 40%

Sharp

40 / 50 / 750

Sharp

(3-day max)

Sharp

1000 ded / 30 / 40

1500 ded / 30 / 30

Sharp HSA

1500 ded / 40 / 40

Sharp

2500 ded / 40 / 40

Sharp

3000 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 40

Sharp HSA

4500 ded / 40 / 50

Sharp

Calendar year deductible (per individual / per family, applies only to those covered benefits indicated)1 _{None None None None None None None None None None $1,000 / $2,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $4,500 / $9,000 $4,500 / $9,000}

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 n/a 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) 1, 2 _{$1,500 / $3,000 $1,500 / $3,000 $1,500 / $3,000 $2,500 / $5,000 $3,000 / $6,000 $3,000 / $6,000 $3,500 / $7,000 $3,500 / $7,000 $4,000 / $8,000 $3,500 / $7,000 $3,500 / $7,000 $3,000 / $6,000 $4,000 / $8,000 $5,000 / $10,000 $6,000 / $12,000 $6,350 / $12,700 $6,000 / $12,000}

Professional

Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $20 $25 $25 $30 $40 $40 $30 $30 6 _{$40 $40 $40} 6 _$40 6 _$40

Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Preventive care services (per visit)3 _{$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0}

Prenatal and postpartum office visits (per visit) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Allergy injections (per visit) $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $10 $30 6 _{$10 $10 $40} 6 _$40 6 _$10

Allergy testing (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Outpatient

Outpatient surgery (per procedure) $0 $0 $125 $125 $250 $250 $500 $500 40% coinsurance 4 _{$750 30% coinsurance} 4,6 _$150 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Laboratory services $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $10 6 _{$0 $0 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$0

Advanced radiology including MRI, CT Scan, PET Scan, MRA, MRS, MUGA, SPECT (per procedure) $0 $0 $100 $100 $100 $100 $100 $100 $100 $100 $100 $50 6 _{$100 $100 30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$100

Physical, occupational and speech therapy (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Hospitalization

Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Emergency / Urgent Care

Emergency room (per visit, waived if admitted for inpatient hospital stay) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150

6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

Urgent care (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $40 6 _{$40 $40 $50} 6 _$50 6 _$50

Ambulance

Ambulance in connection with hospital admission or emergency services $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _$100 6 _$100 6 _$200 6

Durable Medical Equipment

Durable medical equipment 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6 _{50% coinsurance} 4,6

Diabetic supplies 0% coinsurance 0% coinsurance 20% coinsurance 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4 _{20% coinsurance} 4 _{20% coinsurance} 4,6 _{20% coinsurance} 4,6 _{20% coinsurance} 4

Prosthetics, orthotics (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Mental Health

5 Inpatient (per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance

4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40} 6 _$40 6 _{$40 $50}

Chemical Dependency

Inpatient

(per admission, except as noted) $100 $0 $250 $250 $500 $500 $500 / day (3-day max) $500 / day 40% coinsurance 4 _{$750 / day (3-day max) 30% coinsurance} 4,6 _{$250 / day} 6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _{40% coinsurance} 4,6

Outpatient (per visit) $10 $15 $15 $20 $40 $25 $35 $40 $40 $50 $40 $30 6 _{$40 $40 $40} 6 _$40 6 _$50

Emergency services for acute drug or alcohol detoxification (per visit) $50 $75 $100 $100 $100 $100 $100 $150 $100 $150 $150 6 _$100 6 _$150 6 _$150 6 _{30% coinsurance} 4,6 _{40% coinsurance} 4,6 _$200 6

SHPA184.01.14Z © 2015 SHC

Consider us your personal health care assistant

(858) 499-8300 or 1-800-359-2002 | Monday through Friday, 8 a.m. to 6 p.m.

[email protected] | Fax (858) 499-8244 | sharphealthplan.com

Supplemental benefits available with every plan

A portfolio of dental HMO and PPO plans, provided through Premier Access Dental, is also available. For more information, please contact your Account Representative.

*Of contracted rates for covered infertility services.

Plan

Copayment

Rx 33 $5 / $15 / $30 Rx 34 $10 / $20 / $40 Rx 39 $20 / $35 / $70 Rx 41 $15 / $25 / $50 Rx 45 $10 / $25 / $35 Rx 46 $15 / $35 / $50 Prescriptions MedImpact

Service

Plan

Copayment (per visit)

Visits (per year)

Acupuncture

American Specialty Health (ASH)

AC12 $10 12 AC14 $10 15 AC16 $10 20 AC18 $15 12 AC20 $15 15 AC22 $15 20 Chiropractic

American Specialty Health (ASH)

AC10 $15 20 AC11 $15 30 B-LG $10 30 D-LG $10 20 Chiropractic and Acupuncture

American Specialty Health (ASH)

AC2 $5 40 AC3 $10 40 AC4 $10 20 AC24 $10 12 AC26 $10 15 AC28 $10 12 AC30 $15 15 AC32 $15 20 Vision

Vision Service Plan (VSP)

A0 $0 _{Frames/lenses: discount based on retail costs}Eye exam: 1 every 12 months

A2 $20 Eye exam: 1 every 12 months _{Frames/lenses: $20}

A8 $30 _{Frames/lenses: discount based on retail costs}Eye exam: 1 every 24 months

OC $0 Eye exam: 1 every 12 months _{Frames/lenses: $0} Assisted Reproductive

Technologies (ART)

ART A 50% coinsurance* n/a ART B 50% coinsurance* n/a ART C 50% coinsurance* n/a

Plan

Copayment