2025_Wellwise_Non-Medicare_Retiree_PPO_Health_Plan_Document.pdf

The document is a Wellwise Non-Medicare Retiree Health Plan Document for the County of Orange, California, effective January 1, 2025. This comprehensive health plan provides medical expense benefits and prescription drug coverage for retired County of Orange employees and their dependents. The plan offers network and non-network medical services, with varying coverage levels for different types of medical treatments, including preventive care, hospital services, outpatient procedures, emergency services, and specialty medical treatments. The plan includes a prescription drug card program with tiered drug coverage, prior authorization requirements for certain services, and specific guidelines for medical necessity and claims processing.

The plan features a calendar year deductible of $500 for individual network coverage and $1,000 for family network coverage, with higher amounts for non-network providers. The out-of-pocket medical maximum is $2,500 for individuals and $5,000 for families within the network, and $5,000 for individuals and $10,000 for families for non-network services. The plan provides a non-smoker incentive of $50 for retirees who do not use tobacco or participate in a smoking cessation program. Additional benefits include case management services, telehealth options, hearing aid coverage, and a specialty pharmacy program for complex medical conditions. The plan is administered by a third-party claims administrator and includes comprehensive appeal and external review processes for claim denials.