Frequently Asked Questions — Members
If your question is not listed below, please contact Customer Care at (619) 228-2300 or 1-800-359-2002 for assistance. We are here to help.
Covered benefits
Dependents
Emergency and urgent care services
Medical bills / reimbursement
| • | What if I get a bill? |
| • | How can I request reimbursement for medical expenses that I have paid? |
| • | How can I request reimbursement for prescription drugs that I paid for? |
Member ID card
| • | When will I get a member ID card? |
| • | How can I get a new ID card? |
Mental health services
| • | Which mental health services are covered? |
| • | How do I access mental health services? |
Prescription drugs
Primary care physician (PCP)
| • | What is a primary care physician (PCP)? |
| • | How do I choose a PCP? |
| • | Can I choose a different PCP for different members of my family? |
| • | Can I change my PCP? |
Specialists
| • | What is a specialist? |
| • | Does my PCP make the decision about which specialist I see, or am I able to make that decision? |
Wellness
| • | Are the Sharp Health Plan wellness programs covered under my plan? |
| • | Are my dependents eligible for the wellness programs? |
| • | How can I get information about alternative health care programs? |
Other
| • | What is a Plan Medical Group (PMG)? |
| • | What is a Plan Network? |
| • | What are Sharp Blue Choice and Sharp Gold Value? |
Covered benefits
Sharp Health Plan is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services always include coverage for doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams and much more, with varying levels of copayment and/or coinsurance. Coverage for other services varies depending upon what your employer chooses to offer. Check your benefit plan matrix and any other supplemental benefit information to find out which services are covered under your plan.
Most employers will give you a benefits booklet that includes a summary of your benefits. You can contact your employer’s benefits office to request this information. The SharpConnect secure member Web site will also allow you to view a medical benefits summary and other plan documents online. If you prefer, you can call Customer Care to have a benefits summary sent to you.
Except for PCP services, emergency services and obstetric and gynecologic services, you are responsible for obtaining valid authorization before you receive covered benefits. Contact your PCP prior to receiving care, and request prior authorization for those covered benefits. If authorization is approved, obtain the expiration date for the authorization. Sharp Health Plan uses evidence-based guidelines for authorization, modification or denial of services. Plan-specific guidelines are developed and reviewed on an ongoing basis by Sharp Health Plan’s medical director, the Utilization Management Committee and appropriate physicians. You can request a copy of Sharp Health Plan’s medical policy for a particular service or condition by contacting Customer Care.
Sharp Health Plan’s network includes 12 hospitals throughout San Diego and southern Riverside counties. View the full list here. PCPs and specialists work with specific hospitals. If hospitalization is necessary, your doctor will admit you to a hospital that is affiliated with your Plan Medical Group. If you want to make sure that you can use a particular hospital, you should select a medical group that is affiliated with that hospital. Customer Care can advise you on which hospitals are used by our Plan Medical Groups.
Dependents
Yes. If you are enrolled in Sharp Health Plan through your employer, your legally married spouse and unmarried dependent children are eligible. Some employers also cover domestic partners. Call Customer Care or your human resources department for more information.
Unmarried children are covered up to age 19. Coverage may be extended up to age 25 for your unmarried children who are full-time students, depending on the option selected by your employer. Call Customer Care or your human resources department for more information.
No. All family members must live in the plan’s service area to enroll in Sharp Health Plan. Sharp Health Plan’s service area includes all of San Diego County and selected areas of southern Riverside County, defined by zip code.
Yes. If your employer extends coverage to full-time students, your children will be covered for emergency and urgent care services while they are away at school. They receive routine and preventive care services from doctors affiliated with their Plan Medical Group while they are back at home.
Yes, as long as there has been a qualified family change, such as marriage, birth or adoption. Enrollment must occur within 31 days of the time your dependents first become eligible to join (that is, within 31 days of marriage, birth or adoption proceedings).
Contact your employer’s human resources department for instructions and an enrollment change form in order to add your newborn. In general, an eligible newborn child is covered for 31 days from his or her date of birth. To continue coverage beyond this initial period, a newborn must be enrolled within 31 days of birth or adoption.
In most cases, yes. If you are a Sharp Health Plan member when your spouse loses group coverage through his or her employer, your spouse may enroll as a dependent under Sharp Health Plan, so long as enrollment occurs within 31 days of the date that coverage ended under the former health plan.
Emergency and urgent care services
Sharp Health Plan has urgent care centers throughout San Diego and southern Riverside counties. Get location information for Sharp Health Plan's urgent care centers online or call Customer Care. You must contact your PCP for authorization before going to an urgent care center, unless you are assigned to Sharp Rees-Stealy Medical Group (SRS). SRS members do not need authorization before going to SRS urgent care centers. Check the Plan Medical Group on your member ID card to see if you are assigned to Sharp Rees-Stealy.
Sharp Health Plan members have direct access to emergency room treatment, whether in San Diego or anywhere worldwide. If you are not sure whether your situation is an emergency, call your PCP. They can help decide the best way to get treatment and can arrange for prompt emergency care. Members also have access to Sharp Nurse Connection®, Sharp’s nurse advice line, for medical assistance during evenings and weekends. To contact Nurse Connection, call Customer Care at (619) 228-2300 or toll-free at 1-800-359-2002 and select the appropriate prompt.
Health concerns may arise at any hour of the day. Sharp Nurse Connection® is an after-hours nurse advice line. Nurse Connection puts you in contact with registered nurses who can assess your medical situation, suggest self-care or address your problem until you can see your doctor, and advise you where to seek care. To contact Nurse Connection, call Customer Care at (619) 228-2300 or toll-free at 1-800-359-2002 and select the appropriate prompt.
You are covered for emergency and urgent care when you are outside Sharp Health Plan’s service area. If you are admitted to a hospital because of an injury or life-threatening medical emergency, you (or someone acting for you) should immediately notify Sharp Health Plan. In other cases, you should contact your PCP within 48 hours after receiving emergency care. Sharp Health Plan members who need help finding emergency or urgent care services out of the service area can contact Assist America. These services are available if you face a medical emergency while traveling 100 miles or more away from your permanent residence or in a foreign country. For San Diegans that can mean travel to destinations as close as Los Angeles or Mexico. Assist America will immediately connect you to doctors, hospitals, pharmacies and other health care services. Call Assist America at 1-800-872-1414 and provide reference number 01-AA-SHP-09073.
Medical bills / reimbursement
As a Sharp Health Plan member, you will not normally receive a bill from a provider. You are responsible only for paying any copayment or deductible due at the time of your visit. However, sometimes a bill for covered services may be sent to you in error. If you receive a bill in error, don’t worry. Just call Customer Care as soon as possible and explain the situation. We will work with the provider to have the bill sent to Sharp Health Plan.
If you receive emergency or urgent care services outside of San Diego or southern Riverside counties, you may be asked to pay for those services. If that occurs, you can request reimbursement from Sharp Health Plan. We will need a copy of the medical records for that visit, an itemized bill and proof of payment in order to determine if the services are covered. Applicable copayments will apply. Call Customer Care if you have any questions about the reimbursement process.
In some cases, you may be asked to pay for prescription drugs that are normally covered by Sharp Health Plan. For example, if you are traveling outside of California and urgently need to fill a prescription, you can request reimbursement from Sharp Health Plan. In order to determine if the medication is covered, we will need a copy of the print-out from the pharmacy showing the medication you received and a receipt showing proof of payment. Applicable copayments will apply. Call Customer Care if you have any questions about the reimbursement process.
Member ID card
ID cards are mailed to members' homes within a week of enrollment. You will receive an ID card for each member of your family who is enrolled in Sharp Health Plan. If you haven’t received your ID card yet, but you have a doctor’s appointment, you can log in to SharpConnect to print a temporary ID card. New ID cards are mailed whenever a change occurs that affects the information on the card, such as a new PCP, a name change or a new physician phone number. Be sure to use only your most current ID card, and show any new ID cards at your next office visit.
You can get a new ID card by logging on to SharpConnect to order an ID card or to view and print a temporary member ID. If you prefer, you can call Customer Care to request a new ID card. Your new card will arrive within 7-10 business days.
Mental health services
Sharp Health Plan provides coverage for the diagnosis and treatment of severe mental illnesses in members of any age and serious emotional disturbances in children. Mental health benefits include inpatient hospital services, partial hospital services and outpatient services when ordered and performed by a participating mental health professional. Members may also have coverage for treatment of other mental health conditions. For detailed descriptions, please see your health plan benefits and coverage matrix and supplemental benefits.
Members have direct access to Sharp Health Plan providers of mental health services without obtaining a PCP referral. Please call Psychiatric Centers at San Diego toll-free at 1-877-257-7273 whenever you need mental health services.
Prescription drugs
The Sharp Health Plan drug formulary lists all covered medications. View the Drug List online or call Customer Care to find out if your medication is included on Sharp Health Plan’s formulary.
A formulary is a list of covered medications for Sharp Health Plan doctors to use when prescribing medicines for you. A formulary enhances quality of care by encouraging the use of prescription medications that are demonstrated to be safe and effective and that produce superior clinical outcomes. Sharp Health Plan’s goal is to include drugs that are supported by medical research and have the most potential to improve members' health, while also keeping health care coverage affordable.
Sharp Health Plan's Pharmacy and Therapeutics Committee, composed of doctors and pharmacists, meets quarterly to evaluate the formulary. The committee considers newly developed drugs, frequently requested non-formulary drugs and recommendations from plan members, doctors and pharmacists for possible addition to the formulary. The committee reviews a variety of materials in the medical literature, such as peer review journals and independent clinical studies. To be included on the formulary, drugs must be approved by the Food and Drug Administration and supported by medical research to have the most potential to improve members' health.
A generic drug is produced and sold under the chemical name. The Food and Drug Administration certifies that generic drugs are safe and effective, and therapeutically equivalent to their brand-name offering. Generic drugs, when available, are usually the best value, providing the same clinical benefits for substantially less cost. These savings help keep the cost of health care coverage more affordable. For Sharp Health Plan members, most generic drugs have a lower copayment.
Yes. Sharp Health Plan’s formulary includes many commonly prescribed medications, both brand-name drugs and generics. When a generic equivalent is available, it must be dispensed instead of the brand-name drug, unless your doctor specifies that the brand-name drug is medically necessary. Most generic drugs have lower copayments than brand-name drugs.
The formulary is a tool for your doctor to use when determining the most appropriate course of treatment. The presence of a drug on the formulary does not guarantee that your doctor will prescribe it for a particular condition. In some cases, prior authorization from Sharp Health Plan may be required before a drug is approved. View the Drug List online or call Customer Care to find out if your medication requires prior authorization.
Sharp Health Plan’s Drug List includes information on alternative medications that are in the same drug class. If your medication is not listed on the formulary, ask your doctor if a formulary alternative would be appropriate for you.
Yes. Mail order is a convenient, cost-effective way to obtain maintenance drugs. Maintenance drugs are medications that are prescribed to treat or stabilize chronic conditions such as arthritis or hypertension. Maintenance drugs are available for up to a 90-day supply through our prescription home delivery service. View more information about mail order services for prescription drugs or call Customer Care.
Your benefits matrix lists the copayments for prescription drug benefits. To find out the copayment for a specific drug, log in to SharpConnect.
Some drugs require prior authorization by Sharp Health Plan to ensure that you are receiving the appropriate medication for your condition based on a review of medical criteria. Your doctor will provide the necessary information to Sharp Health Plan for the prior authorization review. If you have any questions regarding the prior authorization process, please call Customer Care.
Sharp Health Plan allows you to refill your prescription after you have used at least 70 percent of the prescribed amount. For a 30-day supply, this means you can get a refill 22 days after you last filled the prescription. For a 90-day supply, you can get a refill 64 days after you last filled the prescription. If you try to order a refill at the pharmacy too soon, you will be asked to wait until the allowable refill date. You can find out when you last filled your prescription by logging on to SharpConnect and selecting PersonalHealthRx to check your drug history. If you have any questions about when your prescription can be refilled, ask your pharmacy for assistance or call Customer Care.
Primary care physician (PCP)
A PCP is your personal doctor who is familiar with your health history and who provides or arranges for quality health care for you. If a specialist is needed, your PCP refers you and keeps in contact with your specialist to ensure continuity of care. Doctors who specialize in family practice, internal medicine, general practice and pediatrics are considered PCPs. Your PCP is listed on your member ID card.
Selecting your PCP is a very important and personal choice. We encourage you to select a PCP who best suits your needs. However, if you are unable to select a PCP at the time you enroll in Sharp Health Plan, we will select one for you so that you can access care immediately. For the most up-to-date information on PCPs, go to our online Find a Doctor tool or call Customer Care.
Yes. Each covered family member may choose a different PCP from a different Plan Medical Group. All family members must stay in the same Plan Network.
Yes. In general, it is a good idea to stay with a PCP so that they can get to know your health needs and history. However, with Sharp Health Plan, you may change to a different PCP in your Plan Network whenever you like. If you wish to make a change, you can log in to SharpConnect to use the online Change PCP Form, or you can call Customer Care and we will help you select a new PCP over the telephone. The change will be effective on the first day of the following month.
Specialists
A specialist is a doctor who focuses on one area of medicine. A specialist is trained as an expert in his or her particular field, such as cardiology, neurology or urology. When you need specialty care, your PCP will refer you to a specialist to ensure that you receive proper medical attention and follow-up.
Your PCP will make recommendations for you to consider. Together, you and your doctor will determine the most appropriate specialist for your particular needs. In some cases, you may be able to see a specialist directly without a referral from your PCP. Women have direct and unlimited access to participating obstetricians and gynecologists within their Plan Medical Group for obstetric and/or gynecological services. In addition, members who choose Sharp Rees-Stealy for their PMG have direct access to specialists in allergy treatment, ophthalmology, otolaryngology (ear, nose and throat) and podiatry. Check the Plan Medical Group on your member ID card to see if you are assigned to Sharp Rees-Stealy. If you have any questions about access to a specialist, call Customer Care.
Wellness
Sharp Health Plan members have access to comprehensive online resources for wellness, including a wellness assessment, personal report, multi-week wellness programs on various health topics, customized exercise and meal plans, food logs, health trackers and much more. Additionally, members have access to a health coaching program and can work one-on-one with a coach to reach personal health goals. See the Health & Wellness section for more information.
Yes, your enrolled dependents are eligible for the Sharp Health Plan wellness programs.
The alternative health care programs from Sharp Health Plan offer you discounts of up to 25 percent off usual provider rates on services from an extensive, credentialed network of chiropractors, acupuncturists, massage therapists and dietitians. You may visit any of these providers directly without a physician referral.
You can also get discounts of 15 to 40 percent off suggested retail prices on more than 2,400 health and wellness products, including vitamins, minerals, herbal supplements, homeopathic remedies, sports nutrition products, books, CDs, DVD's, fitness products and skin care items.
Click here for more information. For telephone assistance in locating a provider or ordering products, call 1-877-335-2746.
Other
Sharp Health Plan has several medical groups (called Plan Medical Groups or PMGs) from which you choose your primary care physician (PCP) and through which you receive specialty physician care or access to hospitals and other facilities. In the Sharp Blue Choice network, you can also select a PCP who is contracted directly with Sharp Health Plan. If you choose one of these PCPs, your PMG will be Independent. You receive covered benefits from doctors who are affiliated with your PMG and who are part of your Plan Network. To find out which plan doctors are affiliated with your PMG and part of your Plan Network, refer to the provider directory for your Plan Network or call Customer Care.
A Plan Network is the group of doctors, medical groups and hospitals that are available to you as a Sharp Health Plan member. There are two Plan Networks, Sharp Blue Choice and Sharp Gold Value. In most cases, your employer will select the Plan Network for you. You can then select your PCP and Plan Medical Group from that network. You will find the name of your Plan Network on your member ID card.
Sharp Blue Choice and Sharp Gold Value are Sharp Health Plan’s two Plan Networks. Both networks include Sharp Community Medical Group, Sharp Rees-Stealy Medical Group, Children’s Physicians Medical Group, Greater Tri-Cities IPA and Primary Care Associates Medical Group. The Sharp Blue Choice network also includes the doctors who are contracted directly with Sharp Health Plan, as part of the Independent Plan Medical Group. You will find the name of your Plan Network on your member ID card.
