2025_Sharewell_Retiree_PPO_Health_Plan_Document.pdf

The document is the Sharewell Retiree Health Plan Document for the County of Orange, California, effective January 1, 2025. This comprehensive health plan outlines medical expense benefits, prescription drug coverage, and eligibility requirements for retired County of Orange employees and their dependents. The plan provides a detailed Schedule of Benefits covering network and non-network medical expenses, including preventive care, emergency services, hospital stays, outpatient procedures, and prescription drugs, with specific coinsurance rates, deductibles, and out-of-pocket maximum limits.

The plan features a $5,000 combined family deductible, with an out-of-pocket maximum of $6,000 for network services and $12,000 for non-network services. Prescription drug coverage is administered through a Pharmacy Benefit Manager, with varying coverage levels for generic, preferred, and non-preferred drugs. The plan includes provisions for case management, utilization review, and prior authorization for certain medical services and medications. Coverage extends to retired employees, their legally married spouse or domestic partner, and dependent children, with specific eligibility criteria and exclusions detailed in the document.