SHARP Health Plan Gold 80 Premier HMO Plan Details for 2021- HealthPocket

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Zip Code	90011 (edit)
Applicant	1/22/1986 Male (edit)

Insurance Type	ACA (Obamacare)
Plan Name	SHARP Health Plan Gold 80 Premier HMO
Plan ID	exch-CA2020SHARPHealthPlanGold80PremierHMO
Plan Year	2020
Insurance Provider	Sharp Health Plan
Metal Level	Gold HMO
Plan Type	HMO
Deductible	$0
Out-of-Pocket Maximum	$0
Plan Highlights

Yearly Deductible & Out-of-Pocket
Yearly Deductible - Individual	$0
Yearly Deductible - Family	$0
Separate Drug Deductible - Individual	$0
Separate Drug Deductible - Family	$0
Out-of-Pocket Max - Individual	$7800
Out-of-Pocket Max - Family	$15600
Maximum Cost per Prescription	$250

Doctor Visit
Primary Care Visit	$30 Copay
Specialist Visit	$65 Copay
Other Practitioner Office Visit	$30 Copay
Preventive Care/Screening/Immunization	No Charge

Tests
Laboratory Tests	$40 Copay
X-rays and Diagnostic Imaging	$75 Copay
Imaging (CT/PET Scans, MRIs)	$275 Copay

Drugs
Tier 1 (Most Generic Drugs)	$15 Copay
Tier 2 (Preferred Brand Drugs)	$55 Copay
Tier 3 (Non-Preferred Brand Drugs)	$80 Copay
Tier 4 (Specialty Drugs)	20% Coinsurance

Outpatient Services
Outpatient Facility Fee	$300 Copay
Outpatient Surgery Physician/Surgical Services	$40 Copay
Outpatient Services Office Visits	20% Coinsurance

ER & Urgent Care
Emergency Room Facility Fee	$350 Copay
Emergency Transportation	$250 Copay
Urgent Care	$30 Copay
Emergency Room Professional Fee	No Charge

Hospital
Inpatient Hospital Services	$600 Copay per day up to 5 days
Inpatient Physician and Surgical Services	No Charge

Mental/Behavioral Health
Mental/Behavioral Health Outpatient Services	$30 Copay
Mental/Behavioral Health Inpatient Facility Fee	$600 Copay per day up to 5 days
Mental/Behavioral Health Inpatient Professional Fee	No Charge
Substance Use Disorder Outpatient Services	$30 Copay
Substance Use Disorder Inpatient Facility Fee	$600 Copay per day up to 5 days
Substance Use Disorder Inpatient Professional Fee	No Charge

Pregnancy
Prenatal Care	No Charge
Delivery and Maternity Care Inpatient Facility Fee	$600 Copay per day up to 5 days
Delivery and Maternity Care Inpatient Professional Fee	No Charge

Other Special Needs
Home Health Care Services	$30 Copay
Outpatient Rehabilitation Services	$30 Copay
Habilitation Services	$30 Copay
Skilled Nursing Facility	$300 Copay per day
Durable Medical Equipment	20% Coinsurance
Hospice Services	No Charge
Acupuncture	$30 Copay
Rehabilitative Speech Therapy	$30 Copay
Rehabilitative Occupational and Rehabilitative Physical Therapy	$30 Copay
Well Baby Visits and Care	No Charge
Allergy Testing	$65 Copay
Diabetes Education	No Charge
Nutritional Counseling	Not covered

Children's Vision
Eye Exam for Children	No Charge
Eyeglasses for Children	No Charge

Children's Dental
Child Filling - One Surface	$25 Copay
Child Dental Checkup	No Charge
Child Root Canal - Molar	$300 Copay
Child Medically Necessary Orthodontia	$1000 Copay

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Phone Number
(323) 918-2700
Office Locations
4800 S Central Ave
Los Angeles, CA 90011

4800 S Central Ave Los Angeles CA, 90011

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County
Applicant Info
Applicant
Date of birth
//
Gender
male
female
Income
$

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SHARP Health Plan Gold 80 Premier HMO

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Benefits & Coverage

Yearly Deductible & Out-of-Pocket

Doctor Visit

Tests

Drugs

Outpatient Services

ER & Urgent Care

Hospital

Mental/Behavioral Health

Pregnancy

Other Special Needs

Children's Vision

Children's Dental

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