2025_Wellwise_Medicare_Retiree_PPO_Health_Plan_Document.pdf

The document is a Medicare Retiree Health Plan for the County of Orange, California, specifically the Wellwise Medicare Retiree PPO Health Plan Document effective January 1, 2025. The plan provides comprehensive medical expense and prescription drug benefits for County of Orange retirees and their eligible dependents, covering a wide range of medical services including preventive care, hospital stays, outpatient services, emergency care, and specialty treatments. The plan is administered by a Claims Administrator and includes network and non-network provider options, with specific coinsurance rates, deductibles, and out-of-pocket maximums for different types of medical services.

The plan offers tiered prescription drug coverage with varying coinsurance rates for different drug categories (generic, preferred, and non-preferred drugs), and includes a specialty pharmacy program for complex medical conditions. The out-of-pocket medical maximum is $2,500 for network providers and $5,000 for non-network providers, with a calendar year deductible of $500 for network and $750 for non-network services. The plan also provides additional benefits such as a non-smoker incentive, case management services, and coverage for mental health and substance abuse treatments. The document details extensive appeal procedures, coordination of benefits, and compliance with HIPAA privacy and security regulations.