Zip Code | 90011 |
Applicant | 1/22/1986 Male |
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 |
HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.
HealthPocket.com provides information on insurance products. If you choose to obtain a quote or apply for an insurance plan, you may be transferred to a partner website to complete your request. Always review the privacy and terms of use of the partner website.
HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.