2025_Sharewell_Choice_PPO_Health_Plan_Document.pdf

The document is the County of Orange Sharewell Choice Health Plan Document, a comprehensive health insurance plan for county employees, effective January 1, 2025. This Seventh Amended and Restated PLAN covers medical expense benefits, prescription drug services, and related healthcare provisions for county employees and their dependents. The plan provides network and non-network medical coverage with specific coinsurance rates, deductibles, and out-of-pocket maximum benefits. Eligible employees include regular and limited-term workers averaging 20 or more hours per week, with coverage extending to enrolled dependents.

The health plan includes a $5,000 annual family deductible, with the PLAN paying 90% for most network services and 70% for non-network services after the deductible. The prescription drug card program offers coverage for generic, preferred, and non-preferred drugs, with varying coinsurance rates and quantity limits. The plan features prior authorization requirements for certain medical services and medications, a specialty pharmacy program, and comprehensive utilization review processes. The document outlines detailed claims procedures, appeal mechanisms, and definitions of covered medical expenses, with provisions for case management, telehealth services, and specific benefit limitations.