Choice Customer Service Center 800-558-8003 - … & ENROLLMENT REQUIREMENTS Carrier's Effective Date...

w w w. w o r d a n d b r o w n . c o m

51

HMO Networks:Anthem: Select HMOHealth Net: CommunityCare; WholeCare; Salud HMO y MásKaiser Permanente: Full Sharp: Premier; Performance Sutter Health Plus: FullUnitedHealthcare: Alliance, Focus, SignatureValueWestern Health: Full

Networks vary by benefit plan and may not be available in all ZIP codes within Counties and/or Rating Regions. Check with your Word & Brownrepresentative to verify Network availability.

PPO Networks:Anthem: Select PPO; Advantage PPO

EPO Networks:Anthem: Prudent Buyer - Small Group

RatingRegion

CountiesHMO

NetworksPPO

NetworksEPO

NetworksHSP

Networks

1

Alpine, Amador, Butte, Calaveras, Colusa, Del Norte,Glenn, Humboldt, Lake, Lassen,Mendocino, Modoc, Nevada,Plumas, Sierra, Shasta,Siskiyou, Sutter, Tehama,Trinity, Tuolumne, Yuba

Anthem Select HMO (Nevada Only);Health Net WholeCare;Kaiser Permanente Full;Sutter Health Plus Full (Sutter Only);UnitedHealthcare SignatureValue (Nevada Only)Western Health Advantage Full (Colusa Only)

Anthem Advantage PPO;Anthem Select PPO;

Anthem Prudent Buyer - SmallGroup

Health NetPureCare

2 Marin, Napa, Solano, Sonoma Health Net WholeCare; Kaiser Permanente Full; Sutter Health Plus Full;UnitedHealthcare SignatureValue; Western Health Advantage Full



Health NetPureCare

3 El Dorado, Placer, Sacramento,Yolo

Anthem Select HMO; Health Net WholeCare; Kaiser Permanente Full; Sutter Health Plus Full; UnitedHealthcare SignatureValue;UnitedHealthcare Focus; Western Health Advantage Full



Health NetPureCare

4 San FranciscoAnthem Select HMO; Health Net WholeCare; Kaiser Permanente Full;Sutter Health Plus Full; UnitedHealthcare SignatureValue;UnitedHealthcare Focus; Western Health Advantage Full



Health NetPureCare

5 Contra CostaAnthem Select HMO; Health Net WholeCare; Kaiser Permanente Full;Sutter Health Plus Full; UnitedHealthcare SignatureValue; UnitedHealthcare Focus; Western Health Advantage Full



Health NetPureCare

6 AlamedaAnthem Select HMO; Health Net WholeCare; Kaiser Permanente Full;Sutter Health Plus Full; UnitedHealthcare SignatureValue;UnitedHealthcare Focus; Western Health Advantage Full



Health NetPureCare

7 Santa ClaraAnthem Select HMO; Health Net WholeCare; Kaiser Permanente Full;Sutter Health Plus Full; UnitedHealthcare SignatureValue;UnitedHealthcare Focus



Health NetPureCare

8 San MateoHealth Net WholeCare; Kaiser Permanente Full; Sutter Health Plus Full;UnitedHealthcare SignatureValue; UnitedHealthcare Focus; WesternHealth Advantage Full



Health NetPureCare

9 Monterey, San Benito, SantaCruz

Anthem Select HMO (Santa Cruz Only); Health Net WholeCare (Santa Cruz Only); Kaiser Permanente Full (Santa Cruz Only);Sutter Health Plus (Santa Cruz Only); UnitedHealthcare SignatureValue(Santa Cruz Only); UnitedHealthcare Focus (Santa Cruz Only)



Health NetPureCare (Santa CruzOnly)

10 Mariposa, Merced, SanJoaquin, Stanislaus, Tulare

Anthem Select HMO; Health Net WholeCare; Kaiser Permanente Full;Sutter Health Plus Full; UnitedHealthcare SignatureValue;UnitedHealthcare Focus



Health NetPureCare

11 Fresno, Kings, MaderaAnthem Select HMO (Fresno Only); Health Net WholeCare; KaiserPermanente Full; UnitedHealthcare SignatureValue; UnitedHealthcareAlliance



Health NetPureCare

12 Santa Barbara, San LuisObispo, Ventura

Anthem Select HMO (Ventura Only); Health Net WholeCare; KaiserPermanente Full (Ventura Only); UnitedHealthcare SignatureValue;UnitedHealthcare Focus; UnitedHealthcare Alliance



Health NetPureCare

13 Imperial, Inyo, Mono Anthem Select HMO (Imperial Only); Kaiser Permanente Full (ImperialOnly); UnitedHealthcare SignatureValue (Imperial Only)



N/A

14 KernAnthem Select HMO; Health Net Salud HMO y Más; Health NetWholeCare; Kaiser Permanente Full; UnitedHealthcare SignatureValue;UnitedHealthcare Alliance



Health NetPureCare

15 Los Angeles(906-912, 915, 917, 918, 935)

Anthem Select HMO; Health Net CommunityCare; Health Net Salud HMOy Más; Health Net WholeCare; Kaiser Permanente Full; UnitedHealthcareSignatureValue; UnitedHealthcare Focus; UnitedHealthcare Alliance



Health NetPureCare

16 Los AngelesAll other ZIP Codes

Anthem Select HMO; Health Net CommunityCare; Health Net Salud HMOy Más; Health Net WholeCare; Kaiser Permanente Full; UnitedHealthcareSignatureValue; UnitedHealthcare Focus; UnitedHealthcare Alliance



Health NetPureCare

17 Riverside, San BernardinoAnthem Select HMO; Health Net Salud HMO y Más; Health NetWholeCare; Kaiser Permanente Full; UnitedHealthcare SignatureValue;UnitedHealthcare Focus; UnitedHealthcare Alliance



Health NetPureCare

18 OrangeAnthem Select HMO; Health Net CommunityCare; Health Net Salud HMOy Más; Health Net WholeCare; Kaiser Permanente Full; UnitedHealthcareSignatureValue; UnitedHealthcare Focus; UnitedHealthcare Alliance



Health NetPureCare

19 San DiegoAnthem Select HMO; Health Net Salud HMO y Más; Health NetWholeCare; Kaiser Permanente Full; Sharp Premier; Sharp Performance;UnitedHealthcare SignatureValue; UnitedHealthcare Focus;UnitedHealthcare Alliance



Health NetPureCare

HSP Networks:Health Net: PureCare

ME

DI

CA

L

52

CARRIER CONTACT INFORMATION

Member SupportCaliforniaChoice Customer Service Center 800-558-8003Anthem Blue Cross 855-383-7248Health Net 800-522-0088Kaiser Permanente

English 800-464-4000Spanish 800-788-0616

Sharp Health Plan 800-359-2002Sutter Health Plus 855-315-5800UnitedHealthcare 800-624-8822Western Health Advantage 888-563-2250

Bilingual Support 800-558-8003, Press #9 for Spanish

Internet Support www.calchoice.com

Provider Eligibility Verification 800-558-8003

Broker Services & Commissions 714-542-6992 - Ext. 4390

Broker of Record Changes Fax 714-972-7368

Adds/Terms Fax 714-558-8000E-mail: [email protected]

Billing Questions 800-558-8003

Claims Contact carriers directly

To contact by mail, or for payment submission: CaliforniaChoice

721 South Parker, Suite 200Orange, CA 92868

Tax ID Number 33-0115986

CaliforniaChoice®


UNDERWRITING & ENROLLMENT REQUIREMENTS

Carrier's Effective Date

Premium Amount Required for 20th?

Applications must be dated within:

Spouse/Domestic Partner Employees - 1 application or 2?

Employee Waiver Cards Required at Enrollment?

Must Brokers Carry Errors & Omissions Insurance?

Does Carrier Offer Open Enrollment?

1st of the month only

Balance Due

60 days

Call your Word & Brown representative

Yes

Yes

Yes

CaliforniaChoice

FEES

Enrollment Fee Amount

Type of Enrollment Fee

Monthly Billing Fee

ACA Taxes/Fees

DEDUCTIBLE CREDITPrior carrier deductible credit given?

4th quarter deductiblecarry-over credit given?

Anthem Blue Cross PPOAnthem Blue Cross HMOAnthem Blue Cross EPOHealth Net HMO

Health Net HSPKaiser Permanente HMOSharp Health Plan HMOSutter Health Plus HMO

UnitedHealthcare HMOWestern Health Advantage HMO

Maximum Choice For EmployeesEach employee's health care needs are different. The CaliforniaChoice program provides employees themaximum choice in meeting those needs with these health plans—all within one program:

HMO

PLEASE NOTE: Not all health plans are available in all areas

PRODUCTS OFFERED

EMPLOYEE CHOICE

CaliforniaChoice PPO Guidelines

CaliforniaChoice

CaliforniaChoice®

Platinum HMO APlatinum HMO BPlatinum HMO C

Gold HMO AGold HMO BGold HMO CGold HMO DSilver HMO A

Silver HMO BSilver HMO CSilver HMO D

Bronze HMO ABronze HMO BBronze HMO CBronze HMO D

PPOGold PPO AGold PPO BGold PPO CGold PPO DSilver PPO ASilver PPO B

53

EPOSilver EPO ASilver EPO B

Bronze EPO A

Is Workers' Comp required on corporate officers, partners and sole proprietors?NoIs on-the-job covered for corporate officers,partners and sole proprietors?YesIs there a premium adjustment for 24 hourcoverage?No

24 HOUR COVERAGE

None

N/A

1-8 9-20 21+

$20 $25 $30

See page 12

See Plan Specific EOC or COI

Call your Word & Brown representative

COBRA enrollees are not counted toward total group size.“Life Only” enrollees are not counted toward total group size.“Dental Only” enrollees are not counted toward total group size.

HSPGold HSP ASilver HSP A

Bronze HSP A

ME

DI

CA

L

Plan listing is subject to change. Please see most updated version of either Plan Change Request or Rapid Quote Request forms for most updated plan listing.NETWORK AVAILABILITY CaliforniaChoice

CaliforniaChoice offers health plans in all four of the Affordable Care Act metal tiers: Platinum, Gold, Silver, and Bronze. Employers can choose from two options when it comes to what metal tier(s) to offer employees.

1. Single Metal Tier – offers employees access to the health plans and benefits available in a single tier.2. Tier Choice – offer employees access to the health plans and benefits available in two neighboring metal tiers.


◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal * All groups must include at least one medical enrolled employee who is

not a business owner or spouse of a business owner † Employer contribution is 100% of employee lowest cost HMO plan

or more

ITEMS REVIEWED IN RAF CALCULATIONSPECIAL CONSIDERATIONS CaliforniaChoice

N/A

Employees

Dependents

COVERAGE RESTRICTIONS

Are Commission employees allowed? Yes—commission-only employees are eligible if theyhave a base a salary that is at least minimum wageand are on the quarterly/annual wage report.

Are 1099 employees allowed? No

Are employees covered if traveling out of USA?Only for emergency benefits

Is coverage available for out-of-state employees?Call your Word & Brown representative

Max. percentage of employees residing out-of-stateallowed 49% (Main office must be located in California)

*100%

N/A N/A

1-2 3-100

1-100

50% of lowest cost planfor each employee

N/A

N/A

1 1 100* N/A

1-100 No

1-100 No

*100% ◆70%

N/A N/A

Employees

For Dependents

% of Total Cost:

PLAN ELIGIBILITY REQUIREMENTS

MINIMUM EMPLOYER CONTRIBUTION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE

WRAP* REQUIREMENTS

GROUP Can be written with another SIZE carrier's HMO, HSP, POS or EPO?

GROUP Can be written with another SIZE carrier's PPO or indemnity plan?

100% of employees not coveredby group insurance and 70% of allemployees regardless of othercoverage

†

CaliforniaChoice®

CaliforniaChoice

AFTER INITIAL ISSUE

ENROLLMENT GROUP SIZE

Min. # of employees Max. # of employees

* For plan years commencing on or after January 1, 2016, the definition ofsmall group employer, for purposes of determining employer eligibility inthe small employer market, shall be determined using the method frocounting full-time employees and full-time equivalent employees set forthin Section 4980H(c)(2) of the Internal Revenue Code. If you need helpcalculating this you may visit www.calchoice.com and click on ACVACalculators and use the ACA Full-Time Equivalent calculator.

54

Employees

Dependents

* Indicates flexibility in being offered with products of another carrier.


55

GENERIC VS. BRAND NAME

If generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?

Refer to summary on pages 58-59

If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?

Refer to summary on pages 58-59

PRESCRIPTIONS

FORMULARY VS. NON-FORMULARY

Does carrier use Rx formulary?Refer to summary on pages 58-59

Are non-formulary drugs available?Refer to summary on pages 58-59

MAIL ORDER - 90 DAY SUPPLYRefer to summary on pages 58-59

CaliforniaChoice®

KEY TO HEALTH CARE SERVICE PLANS OFFERING LISTED PROGRAM:

ABC Anthem Blue CrossHN Health NetKP Kaiser PermanenteSH Sharp Health PlanST Sutter Health PlusUHC UnitedHealthcareWH Western Health Advantage

* All CaliforniaChoice® medical members are eligible for discounts on eye exams, lenses, frames, and contacts through the VisionOne Eye Care Program administered by EyeMed Vision Care (provided by Ameritas).

1 Discounts of frames and lenses available through Kaiser Permanente facilities.

2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which links Kaiser Permanentemembers to Healthy Roads.

3 Member must use a Kaiser Permanente weight loss program.

Which health care plans offer these discounts, awards and other value-added benefits?Eyewear & lenses discount ..................................................................................................................ABC, HN, KP 1, UHCHealth club membership or fitness equipment/sporting goods discount ..........................ABC, HN, KP, SH, UHC, WHHealth literature, telephone tapes and/or videos (no charge) ........................................................HN, KP, SH, ST, UHC available in the following languages: Spanish (Except ST), Chinese (UHC Only), Korean (UHC Only), Japanese (UHC Only), and Vietnamese (UHC Only)Personalized, dynamic online tools on health information ................................................................ABC, ST, UHC, WHHome childproofing products discount ................................................................................................................ABC, HNInfant car seat: discount ............................................................................................................................................................HN awarded upon prenatal class completion ........................................................................................................HNNurses 24 hour hotline ....................................................................................................ABC, HN, KP, SH, ST, UHC, WHVitamins and/or herbal supplements discount............................................................................ABC, HN, KP 2, SH, UHCWeight control program discount ................................................................................................ABC, HN, KP 3, SH, UHC

DISCOUNTS*, AWARDS & OTHER VALUE-ADDED BENEFITS CaliforniaChoice

ME

DI

CA

L


PROVIDER INFORMATION CaliforniaChoice®

HMO

Anthem Blue Cross Health Net

Kaiser Permanente

SharpHealth Plan

SutterHealth Plus

How often can familymembers change theirPrimary CarePhysician? (PCP)

Once a month – changesare effective at thebeginning of the followingmonth, provided themember is not in thecourse of treatment orhospitalized and no pending authorizations.

Once a month Anytime Once a month Monthly - if made prior to15th of month, change iseffective first of followingmonth

Can family memberseach choose a PCPfrom a differentIPA/Medical Group?

Yes Yes Yes—from KaiserPermanentePhysicians

Yes Yes

Do plans have these types of programs to speed the specialist referral process in network: Self referral? Express referral?

Yes – referrals comedirectly from PCP

HMO: Self: Yes— if Rapid Access provider

Self: Yes—to OB/GYN andcertain other specialties(list varies by region)Express: Yes—referraldirect from physician

Self: Yes—if availablethrough medical group

Members may seekassistance from MemberServices or the NurseAdvice Line. Mostspecialists require a referral only from the PCP, and do not requirePrior Authorization. OncePCP enters the referral, it is immediately sent to the specialist office for scheduling.

Is there an Out-of-Network benefit?

No No No No No

PRESCRIPTIONS CaliforniaChoice

If generic available,and doctor has notindicated “dispense aswritten,” will memberreceive a genericequivalent rather thana name brand drug?

Yes Yes—or you must paybrand copay + differencein cost between brandname & generic equivalent

Yes Yes Yes - This decision is doneat the pharmacy with thefinancial incentive for themember and pharmacy togo with generics. SHP mayrequire PA for try and failthe generic and will have ahigher copay for the brand.

If doctor writes “dispense as written”on prescription, is brand name available at the brand copay?

No Yes Yes Yes Yes - Tier 3 - Non-Preferredbrand name medicationsare covered at the third tierCost Share level. Thesegenerally have a preferredand often less costlytherapeutic alternative at alower tier.

Does health plan use Rx formulary?

Yes Yes Yes Yes Yes

If medically necessary, are non-formulary drugs covered?

Yes†— non-formularycopay applies

†Prior authorization mayrequired for certainmedications



Yes—if deemed medicallynecessary by Health PlanPhysician



Yes, with priorauthorization, justificationrequired for medicalnecessity for non-formularydrug

NOTE: Each HCSP HMO has their own PCP change approval process

56

BENEFIT SUMMARY

Prescription copay charts are located on pages 58-59


PROVIDER INFORMATION CaliforniaChoice®

HMO HSP EPO PPO

UnitedHealthcareWestern

Health Advantage Health Net Anthem Blue CrossAnthem Blue

Cross Life and HealthInsurance Company

How often can familymembers change theirPrimary CarePhysician? (PCP)

Anytime Once a month—changesare effective atbeginning of thefollowing month,provided the member is not in the course oftreatment or hospitalizedand no pendingauthorizations

Changing the PCPfollows normal HMOguidelines; however,please note a membercan self refer to any PCPcontracted within theHSP network

N/A - PCP selection isnot required

Anytime—in a PPO, youdo not have to choose aPCP

Can family memberseach choose a PCPfrom a differentIPA/Medical Group?

Yes—but only fromnetwork of physicians

Yes—but only fromnetwork physicians

N/A N/A - PCP selection isnot required

Yes—each family membercan make their ownphysician choice

Do plans have these types of programs to speed the specialist referral process in network: Self referral? Express referral?

Depends on theagreements with themedical group.

Yes—Advantage Referral Program allowsPCP to refer member toany specialist in theWHA network whoparticipates in theAdvantage ReferralProgram

HSP is a self referralproduct

N/A - PCP selection isnot required

Yes – in a PPO, you don'thave to go through aspecialist referral process

Is there an Out-of-Network benefit?

No No No - Only emergencyservices are covered Outof network

Yes—Negotiated FeeSchedule

Yes—Negotiated FeeSchedule

PRESCRIPTIONS

If generic available,and doctor has notindicated “dispense aswritten,” will memberreceive a genericequivalent rather thana name brand drug?

Yes Yes—or you must paythe brand copay plusthe difference in costbetween the brandname and genericequivalent

Yes Yes—or you must paythe generic copay plusthe difference in costbetween the brandname & genericequivalent

Yes—or you must pay thegeneric copay plus thedifference in cost betweenthe brand name & genericequivalent

If doctor writes “dispense as written”on prescription, is brand name available at the brand copay?

Yes Yes We will cover BrandName drugs, includingSpecialty Drugs, that havegeneric equivalents onlywhen the Brand NameDrug is MedicallyNecessary and thePhysician obtains PriorAuthorization from HealthNet

No—member will haveto pay the generic copayplus the difference incost between genericand brand

No—member will have topay the generic copay plusthe difference in costbetween generic andbrand

Does health plan use Rx formulary?

Yes Yes Yes, the Essential DrugFormulary is utilized

Yes Yes

If medically necessary, are non-formulary drugs covered?

Yes Yes†— non-formularycopay applies

†Prior authorization maybe required for certainmedications

Yes Yes - see pages 58-59 Yes - see pages 58-59

NOTE: Each HCSP HMO has their own PCP change approval process

ME

DI

CA

L

57

BENEFIT SUMMARY

Prescription copay charts are located on pages 58-59


PRESCRIPTION COPAYS CaliforniaChoice®

HMO

What is copay for covered non-formulary drugs?

Anthem Blue Cross Health Net

Kaiser Permanente

SharpHealth Plan

SutterHealth Plus

Platinum HMO A $70 $50 $15 $50 $25

Platinum HMO B -- $50 $15 $50 $25

Platinum HMO C -- -- -- $50 --

Gold HMO A $80 $60 $50** $70 $25**

Gold HMO B -- $60 $55 $70 $75

Gold HMO C -- -- -- $70** --

Gold HMO D -- -- -- -- --

Gold HSP A -- -- -- -- --

Silver HMO A $110 50% -- $80 --

Silver HMO B -- 50% $70 $100 $85

Silver HMO C -- -- $55 $100** $40*

Silver HMO D -- -- 80% (up to $250 per Rx)* -- --

Silver HSP A -- -- -- -- --

Silver EPO A -- -- -- -- --

Silver EPO B -- -- -- -- --

Bronze HMO A -- -- 100% (up to $500 per Rx) $100 100%† (up to $500 per Rx)

Bronze HMO B -- -- -- 60% (up to $500 per Rx)* 60% (up to $500 per Rx)*

Bronze HMO C -- -- 60% (up to $500 per Rx)* -- --

Bronze HMO D -- -- -- $100* --

Bronze HSP A -- -- -- -- --

Bronze EPO A -- -- -- -- --

Bronze EPO B -- -- -- -- --

Mail order

Anthem Blue Cross Health Net Kaiser

PermanenteSharp

Health PlanSutter

Health Plus

90 day supply— 90 day supply—double retail copay

100 day supply—double retail copay

90 day supply—double retail copay

90 day supply—

Platinum HMO A $13 or $38/$105/$210 $10/$40/$100 $10/$30/$30 $20/$50/$100 $10/$30/$50

Platinum HMO B -- $10/$40/$100 $10/$30/$30 $20/$50/$100 $10/$30/$50

Platinum HMO C -- -- -- $20/$50/$100 --

Gold HMO A $13 or $50/$120/$240 $20/$100/$120 $30**/$100**/$100** $38**/$70/$140 $10**/$30**/$50**

Gold HMO B -- $20/$100/$120 $30/$110/$110 $38**/$70/$140 $30/$110/$150

Gold HMO C -- -- -- $20**/$80**/$140** --

Gold HMO D -- -- -- -- --

Gold HSP A -- -- -- -- --

Silver HMO A $13 or $50/$210/$330 $40/50%/50% -- $40**/$100/$160 --

Silver HMO B -- $40/50%/50% $50**/$140/$140 $40**/$100/$200 $30/$110/$170

Silver HMO C -- -- $30/$110/$110 $40**/$100**/$200** $20*/$40*/$80*

Silver HMO D -- --80% (up to $250 per Rx)*/80% (up to $250 per Rx)*/80% (up to $250 per Rx)*

-- --

Silver HSP A -- -- -- -- --

Silver EPO A -- -- -- -- --

Silver EPO B -- -- -- -- --

Bronze HMO A -- --100% (up to $500 perRx)/100% (up to $500 perRx)/100% (up to $500 per Rx)

$38**/$120/$200 100%† (up to $1,000 per Rx)

Bronze HMO B -- -- --60% (up to $500 per Rx)*/60% (up to $500 per Rx)*/60% (up to $500 per Rx)*

60% (up to $1,000 per Rx)*/60% (up to $1,000 per Rx)*/60% (up to $1,000 per Rx)*

Bronze HMO C -- --60% (up to $500 per Rx)*/60% (up to $500 per Rx)*/60% (up to $500 per Rx)*

-- --

Bronze HMO D -- -- -- $60*/$140*/$200* --

Bronze HSP A -- -- -- -- --

Bronze EPO A -- -- -- -- --

Bronze EPO B -- -- -- -- --†Generic copay/brand name copay/non-formulary copay, the Brand Rx deductible will apply if applicable.

58

* HSA Qualified High Deductible Health Plan** Overall Deductible Waived† Covered in full after out-of-pocket maximum is met.

BENEFIT SUMMARY


PRESCRIPTION COPAYS CaliforniaChoice®

HMO HSP EPO PPO

What is copay for covered non-formulary drugs? UnitedHealthcare

WesternHealth Advantage Health Net

Anthem BlueCross

Anthem Blue Cross Life andHealth Insurance Company

Platinum HMO A $50 $50 -- -- Participating Pharmacy: $80

Non-Participating Pharmacy: Not covered

If applicable, a Brand Rx deductibleof $250/$500 will apply:

Gold PPO A**Gold PPO BGold PPO C**Gold PPO DSilver PPO ASilver PPO B

Platinum HMO B $50 $25 -- --

Platinum HMO C $50 -- -- --

Gold HMO A $70 $75 -- --

Gold HMO B $70 $75 -- --

Gold HMO C $70 $75 -- --

Gold HMO D -- $50 -- --

Gold HSP A -- -- 60% (up to $250 per Rx)** --

Silver HMO A $100 $85 -- --

Silver HMO B $100 $85 -- --

Silver HMO C $100 80% (up to $250 per 30 day supply)* -- --

Silver HMO D $100 -- -- --

Silver HSP A -- -- 50% (up to $250 per Rx)** --

Silver EPO A -- -- -- $80**

Silver EPO B -- -- -- 80% (up to $250 per Rx)*

Bronze HMO A -- -- -- --

Bronze HMO B 100%* 100%† (up to $500 per Rx) -- --

Bronze HMO C $150 Copay 100%* -- --

Bronze HMO D -- 60% (up to $500 per 30 day supply) -- --

Bronze HSP A -- -- 50% (up to $500 per Rx) --

Bronze EPO A -- -- -- $100

Bronze EPO B -- -- -- --

Mail order UnitedHealthcare Western

Health Advantage Health Net Anthem Blue Cross Anthem Blue Cross Life andHealth Insurance Company

90 day supply—doubleretail copay 90 day supply— 90 day supply:

$13 or $50/$120/$240

Non-Participating Pharmacy: Not covered

If applicable, a Brand Rx deductibleof $250/$500 will apply:

Gold PPO A**Gold PPO BGold PPO C**Gold PPO DSilver PPO ASilver PPO B

Platinum HMO A $30/$70/$100 $25/$75/$125 -- --

Platinum HMO B $30/$70/$100 $13/$38/$63 -- --

Platinum HMO C $30/$70/$100 -- -- --

Gold HMO A $30/$70/$140 $50/$125/$188 -- --

Gold HMO B $30/$70/$140 $38/$138/$188 -- --

Gold HMO C $30/$70/$140 $25**/$125/$188 -- --

Gold HMO D -- 100%/$75*/$125* -- --Gold HSP A -- -- $10**/$40**/60%(up to

$750 per Rx)** --

Silver HMO A $50**/$100/$200 $38**/$138/$213 -- --

Silver HMO B $50**/$100/$200 $38/$138/$213 -- --

Silver HMO C $50**/$100/$200

80%*(up to $650 per Rx)/80%*(up to $650 perRx)/80%(up to $650 perRx)*

-- --

Silver HMO D $50**/$100/$200 -- -- --

Silver HSP A -- -- $20**/$60**/50% (up to$750 per Rx)**

$13 or$50**/$120**/$240**

Silver EPO A -- -- -- --

Silver EPO B -- -- --80% (up to $750 per Rx)*/80% (up to $750 per Rx)*/80% (up to $750 per Rx)*

Bronze HMO A -- -- -- --

Bronze HMO B 100%*/100%*/100%* 100%††(up to $1,250 perRx) -- --

Bronze HMO C $50**/$200/$300 100%*/100%*/100%* -- --

Bronze HMO D --

60%*(up to $1,250 perRx)/60%* (up to $1,250per Rx)/60%* (up to $1,250 perRx)

-- --

Bronze HSP A -- -- $30**/$90/50% (up to$1,500 per Rx) --

Bronze EPO A -- -- -- $13 or $50**/$180/$300

Bronze EPO B -- -- -- --†Generic copay/brand name copay/non-formulary copay, the Brand Rx deductible will apply if applicable.

59

ME

DI

CA

L

* HSA Qualified High Deductible Health Plan** Overall Deductible Waived† Covered in full after out-of-pocket maximum is met.

BENEFIT SUMMARY

60


BENEFIT SUMMARYDIABETIC BENEFITS CaliforniaChoice®

HMO

Anthem Blue Cross Health NetKaiser

PermanenteSharp

Health PlanSutter

Health Plus

Are the following items covered under the Prescription DrugBenefit, DurableMedical EquipmentBenefit or DiabetesCare Benefit of the member’s selected plan design?

Insulin PrescriptionDrug Benefit

PrescriptionDrug Benefit



Prescription DrugBenefit

Needles & Syringes PrescriptionDrug Benefit





Chem-Strips and/orTesting Agents

(Blood Test Strips)Covered under thePrescription Drug Benefits


Blood test strips are coveredunder Durable MedicalEquipment; Urine test stripsare covered underPrescription Drug Benefit

Diabetes Care Benefit,rather than PrescriptionDrug Benefit


Insulin Pump Supplies Durable MedicalEquipment Benefit

Covered at plan copayor coinsurance. Seeplan specific EOC fordetails

Durable MedicalEquipment Benefit,rather than PrescriptionDrug Benefit


Durable MedicalEquipment Benefit

Glucose Monitor† Free Glucometer Program forcertain manufacturers;otherwise, covered underDurable Medical EquipmentBenefit

Covered as Medical Suppliesrather than Prescription DrugBenefit:All other monitors covered atplan copay or coinsurance. Seeplan specific EOC for details




Insulin Pump† Durable MedicalEquipment Benefit

Covered at plan copayor coinsurance. Seeplan specific EOC fordetails




† Vendors for Diabetes Equipment:

Please see carrier web-site for list ofproviders

Benefits are typically coveredunder the pharmacy benefitwith participating pharmacies.Health Net will only covercertain machines.

Pending ADS(Advanced Diabetes Supply) 390 Oak Avenue, Suite NCarlsbad, CA 92008800-730-9887

Participating pharmaciesand Durable Medicalproviders, as applicable

SELF-INJECTABLE DRUG BENEFITS CaliforniaChoice

Are self-injectabledrugs (other thaninsulin) covered underthe Prescription Drugbenefit or MedicalBenefit?

May depend on themedication. CallPharmacy Services at 800-700-2533 to confirm

Medical Benefit


May depend onmedication

Generally the PrescriptionDrug Benefit - Howeverthere is an exceptionprocess to cover under theMedical benefit if appropri-ate.

Is pre-authorizationrequired?

Some medicationsand/or dosagesmay requireprior authorization

Yes Must be prescribedby a plan physician

Some medicationsand/or dosages mayrequire priorauthorization

The Prior-Authorizationrequirement is drugspecific depending onmany factors withsafety as a primaryfactor.

Must self-injectables(other than insulin) bepurchased via the carrier-contracted mailorder RX vendor?

Certain drugs must gothrough mail-orderprovider. CallPharmacy Services at 800-700-2533 toconfirm

No—use doctor'scontracted vendor

Must use planpharmacies (includingaffiliated pharmacies)

No—mail order notrequired

No


61

ME

DI

CA

LBENEFIT SUMMARY

DIABETIC BENEFITS CaliforniaChoice®

HMO HSP EPO PPO

UnitedHealthcareWestern

Health Advantage Health Net Anthem Blue CrossAnthem Blue

Cross Life and HealthInsurance Company

Are the following items covered under the Prescription DrugBenefit, DurableMedical EquipmentBenefit or DiabetesCare Benefit of the member’s selected plan design?

Insulin PrescriptionDrug Benefit





Needles & Syringes PrescriptionDrug Benefit





Chem-Strips and/orTesting Agents




(Blood Test Strips)Covered under thePrescription DrugBenefits

(Blood Test Strips)Covered under thePrescription DrugBenefits

Insulin PumpSupplies


Durable MedicalEquipment Benefit, rather thanPrescription DrugBenefit




Glucose Monitor† Durable MedicalEquipment Benefit



Free GlucometerProgram for certainmanufacturers;otherwise, coveredunder Durable MedicalEquipment Benefit

Free GlucometerProgram for certainmanufacturers;otherwise, coveredunder Durable MedicalEquipment Benefit

Insulin Pump† Durable MedicalEquipment Benefit





† Vendors for Diabetes Equipment:

Please see carrierwebsite for list ofproviders

Contract is withMedical Group.See PCP

Participating HNPharmacy orParticipating HN DMEProvider

Please see carrierwebsite for list ofproviders

Please see carrierwebsite for list of providers

SELF-INJECTABLE DRUG BENEFITS CaliforniaChoice

Are self-injectabledrugs (other thaninsulin) covered underthe Prescription Drugbenefit or MedicalBenefit?

Medical Benefit Medical Benefit Self-injectable drugs(other than insulin) areconsidered to be specialtydrugs and covered underthe specialty prescriptionbenefit of the plan

May depend on the medication. Call PharmacyServices at 800-700-2533 to confirm

May depend on the medication. CallPharmacy Services at800-700-2533 to confirm

Is pre-authorizationrequired?

Some medicationsand/or dosages mayrequire priorauthorization

Yes Yes Some medicationsand/or dosages mayrequire priorauthorization. CallPharmacy Services at 800-700-2533 to confirm

Some medications and/ordosagesmay require priorauthorization. CallPharmacy Services at 800-700-2533 to confirm

Must self-injectables(other than insulin) bepurchased via the carrier-contracted mailorder RX vendor?

Yes—depends onmedical group

Depends onmedical group

Self-injectable drugs(other than insulin)must be purchasedfrom a specialtypharmacy vendorand are not eligiblefor the mail order RXprogram

Certain drugs mustgo through mail-order provider. Call PharmacyServices at 800-700-2533 to confirm

Certain drugs must go through mail-orderprovider. Call Pharmacy Services at 800-700-2533 to confirm


62

BENEFIT SUMMARYPEDIATRIC COVERAGE CaliforniaChoice®

HMO

Anthem Blue Cross Health NetKaiser

Permanente

Do you send out aseparate PediatricDental and Vision card to employeehousehold (for those that havedependent coverage 18 and under?)

No A pediatric dental ID card is sent to thesubscriber’s home address; however,Health Net does not issue a pediatricvision ID card. Members may accesspediatric vision services by presentingtheir Health Net ID card.

Dental: Delta provides the following forthe bundled pediatric dental policyattached to the medical policy. Theprimary enrollee (subscriber) is listed onthe card. The enrollee info withassigned dentist is under coveragedetails. The reason why primaryenrollee is listed is because dental apptsand Delta customer service uses theprimary MRN to get the Delta ID number(Region code +variable 0's+ MRN=12digits) . The subscriber information iskey information. Once the subscriber isfound, the information for thedependents fall under the subscriber forthe records to be pulled.

Vision: Medical Card.

Is the ID card underthe Dependents name?

N/A No. Dental : See above.

Vision: Yes.

If the employee hasdependent children 18 and under and alsoenrolls in the groupdental program,which plan is primary?

Assuming that the EE and dependent arethe same on both policies, the policythat was effective first is the primarydental policy. If they are both effectiveon the same date, the pediatric dentalplan would be the primary policy.

The pediatric dental PPO plan will beprimary (please note, there is nocoordination of benefits for pediatricDHMO or buy up DHMO plans).

Dental: The current rules that pertain tothe determination of the order ofbenefits (most states follow the NAICModel Rule for COB) would apply. Forexample:

First – look to the birthday rule for theprimary enrollee under the plans – ThePE who has the earlier birthday in theyear is primary and the other issecondary.

Second – if the first rule doesn’t resolveit, e.g. they are the same PE or the twoPEs have the same birthday – then lookto the older plan, i.e. the one thatprovided coverage for the child first;

Third – if neither First or Seconddetermine the order – if one plan is amedical plan and the other a dental plan– then the medical plan is primary andthe dental plan secondary;

Vision: N/A

Is there coordination of benefits between the group dental planand the MedicalPediatric Dental andVision program?

Yes There is coordination of benefitsbetween the group dental DPPO planand the medical pediatric DPPO benefits.Coordination of benefits are notavailable for DHMO plans or visionplans.

Dental: See above.

Vision: The vision benefits are built intothe medical plan.


63

BENEFIT SUMMARYPEDIATRIC COVERAGE CaliforniaChoice®

HMO

SharpHealth Plan

SutterHealth Plus UnitedHealthcare

WesternHealth Advantage

Do you send out aseparate PediatricDental and Vision card to employeehousehold (for those that havedependent coverage 18 and under?)

No, they should use theirmedical ID card Pediatricmembers will get their ownID card from Access Dentalin addition to getting anSHP ID card. This isAccess Dental’s usualpractice.

No, they should use theirMedical ID card.

Dental Response – Yes, aseparate Pediatric Dental IDcard is sent at the time eligi-bility is processed.

Vision ID cards are notmailed. Members can visitmyuhcvision.com (directly orvia the link on myuhc.com)to print an ID card ondemand. ID cards are notrequired for service.

Dental: Yes, Delta Dentaldoes provide an ID card tothe EHB member.

Vision: Medical EyeServices (MES) does notsend vision ID cards. Themember can go to the MESwebsite to print a card.

Is the ID card underthe Dependents name?

N/A, the pediatric dental IDcard has the Dependent’sname only; if more than 1child in the family, eachmember will receive theirown card from AccessDental.

Yes Dental Response – No, theID card is provided underthe subscriber name and itis one card that applies toall dependents under thesubscriber.

Vision, from portal: Info isbased on member/plan youare viewing. If viewing thedependent, the dependentsname and ID are on thecard.

Dental: Yes, each ID Cardis specific to the member,indicating their own uniqueID and Providerelection/assignment. If onehas not been elected thecarrier will provide a letterexplaining how to do so.

Vision: No, the ID cardshave the employee'sinformation.

If the employee hasdependent children 18 and under and alsoenrolls in the groupdental program,which plan is primary?

Pediatric Dental EHBPediatric Dental is primary.If the group also has adental plan, some servicesmight be billed under thatplan.

Pediatric Dental is primary. Medical Pediatric Dental planand a UHC standalone plan,then the UHC MedicalPediatric Dental plan isprimary and the UHCstandalone plan would besecondary.

For Vision, we do not COB.

Dental: The EHB plan isDHMO, therefore to receivebenefits, a member must seetheir PCD. Should themember have duplicatepediatric coverage (under 19years), then the plan issecondary (pg. 15 of theEOC).

Vision: The child is primaryand the parent's coverage issecondary.

Is there coordination of benefits between the group dental planand the MedicalPediatric Dental andVision program?

Yes, pediatric dental isprimary.

Yes, pediatric dental isprimary

Dental Response – If themember has a UHCMedical Pediatric Dentalplan and a UHC standaloneplan, then yes, we offercoordination of benefitsand claims are internallyprocessed under bothplans, if the member hasone plan with UHC and theother with another carrier,then, no coordination ofbenefits. Member wouldneed to submit claim toone and then the other.

There is no COB betweenmedical plans and visionplans. Claims may besubmitted to either plan.

Dental: Based on above,there would be nocoordination of benefits.Due to the nature of aDHMO product, and thisproduct being secondary,there is no situation wherethis would be applicable.

Vision: Yes.

ME

DI

CA

L

Choice Customer Service Center 800-558-8003 - … & ENROLLMENT REQUIREMENTS Carrier's Effective Date...

Documents

Transcript of Choice Customer Service Center 800-558-8003 - … & ENROLLMENT REQUIREMENTS Carrier's Effective Date...