2025 Wellwise Choice PPO Health Plan Document Summary

This is a health plan document for the Wellwise Choice PPO plan administered by the County of Orange, California, in conjunction with Blue Shield of California and Alight Solutions. The document outlines the pharmaceutical benefits and coverage details for employees, non-Medicare retirees, Medicare retirees, and their dependents enrolled in the Wellwise Choice PPO option. The plan includes comprehensive prescription drug coverage through a pharmacy benefit management program, with detailed formularies, copayment structures, and clinical management programs designed to control costs while maintaining access to necessary medications. The document specifies network pharmacy services, mail-order pharmacy options, and specialty pharmacy provisions for high-cost medications. The Wellwise Choice PPO plan operates as part of the County's broader health benefits portfolio alongside other plan options including Sharewell Choice and various retiree plans.

The plan document establishes pricing structures through tiered copayment systems for generic, preferred brand, and non-preferred brand medications, with separate cost-sharing provisions for specialty drugs and mail-order prescriptions. The plan incorporates clinical management programs including prior authorization requirements, step therapy protocols, and quantity limits to optimize therapeutic outcomes and manage expenses. The Wellwise Choice PPO is funded through the County's self-insured health plan arrangement, with Blue Shield of California serving as the medical plan administrator and the selected PBM (currently OptumRx) managing claims processing, network management, and pharmacy operations. The document reflects the existing pharmacy benefit structure that the County intends to evaluate through its RFP process to determine whether to continue with the incumbent vendor or transition to an alternative PBM provider effective January 1, 2026.