2025_Wellwise_Choice_PPO_Health_Plan_Document.pdf

The document is the Wellwise Choice 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 administrative procedures for county employees. The plan provides network and non-network medical coverage with specific deductible levels, out-of-pocket maximums, and coinsurance rates for various medical services including preventive care, hospital stays, outpatient procedures, emergency services, and specialty treatments. The plan covers regular and limited-term employees working 20 hours or more per week, along with their eligible dependents.

The health plan features a tiered prescription drug card program with different coinsurance levels for network and non-network pharmacies, covering a wide range of medications with varying cost-sharing structures. The plan includes provisions for prior authorization for certain medical services and medications, utilization review processes, and detailed appeal procedures. The Pharmacy Benefit Manager administers the prescription drug component, with a formulary that includes generic, preferred, and non-preferred drugs. The plan also incorporates HIPAA privacy and security provisions, and provides comprehensive definitions of medical terms, covered services, and exclusions. The document was prepared by the County of Orange's Human Resource Services and is set to be implemented on January 1, 2025, with the potential for future amendments.