What is changing?
Our formulary (or drug list) will be changing for 2020. There will be more positive formulary changes than negative. We will cover non-formulary drugs only when their use has been determined to be medically necessary after a review of a member’s specific needs. There will also be some tier, specialty drug and utilization management changes, including new step therapy, prior authorization and quantity limit requirements. In November, you will be able to see the 2020 formulary here.
Why is the formulary changing?
Formularies change as new drugs are approved, and more information about new uses for drugs becomes available. These formulary changes help us to ensure that our formulary is up-to-date and includes the latest safety data and FDA-approved prescribing information.
How will I know if the formulary changes impact me?
We will notify members of any potential formulary changes by mail in November and December. These notices will only be sent to members who are taking medication that will be affected by changes to the formulary. If you get a letter from us, you will be directed to work with your doctor if you have questions. Your doctor will be notified of these changes too so that they are prepared to assist you with questions.
When will the new formulary be effective?
The new formulary will be effective Jan. 1, 2020. If you are enrolled in benefits on our Tier 3 formulary (meaning you have 3 levels of pharmacy copays), and you are taking a medication that is negatively impacted by the formulary changes for next year, then you will have a 31-day grace period (until Feb. 1, 2020) on those medications. We will notify you and your doctor of your specific formulary effective dates in our communications that are mailed November through December. If you aren’t sure what Tier formulary you’re enrolled in, and want to check, please log in to your Sharp Connect account or email Customer Care at firstname.lastname@example.org or call 1-800-359-2002.
Who should I contact with questions about my medications?
If you have questions about your medications for 2020, please work with your doctor. For all other questions contact our Customer Care team at email@example.com or 1-800-359-2002. We are available to assist you Monday through Friday, 8 am to 6 pm. Beginning Jan. 1, 2020 we’re excited to offer a new, dedicated prescription helpline that will be available for members to call with pharmacy-related questions. The helpline will be available 24/7 at 1-855-298-4252.
What if I have a prior authorization for my current medication?
All existing pharmacy prior authorizations will remain in effect until the date noted on your original approval letter from Sharp Health Plan. If you no longer have your approval letter, please contact Customer Care at firstname.lastname@example.org or 1-800-359-2002 before the end of the year so that we can assist you.
Is your pharmacy network changing?
Our pharmacy network (where prescriptions can be filled) will remain 99% the same in 2020. You can continue using all Sharp® pharmacies, in-network community pharmacies, and retail pharmacy chains such as Albertsons®, Costco®, Ralphs®, Rite Aid®, Vons®, Walgreens® and Walmart® in addition to CVS Pharmacy® stores. Visit sharphealthplan.com/findapharmacy to find a pharmacy near you.
Can I continue filling my prescriptions at a pharmacy that is no longer a part of my network?
Yes, but you will be responsible for the full cost of your medication. For the best customer experience, we encourage you to use a pharmacy in your network. Visit sharphealthplan.com/findapharmacy to find a pharmacy near you.
Will I get a new member ID card?
Yes. New member ID cards will be mailed in December. These cards will include new BIN and PCN information, which is used by pharmacies when you fill a prescription. Cards will also include a new, dedicated pharmacy telephone number for 24/7 support. Beginning Jan. 1, 2020, you should use your new ID card whenever getting care or filling prescriptions. See samples of the new ID cards. Please note that we mail member ID card(s) separately and each mailing will include a maximum of two cards. If your plan includes three or more family members, you should expect multiple mailings.
What is the new pharmacy telephone number?
Our new dedicated prescription helpline will be available beginning Jan. 1, 2020. The number will be printed on the back of your new member ID card, and will be available on our Contact Us page.
24/7 Prescription Helpline
Do I need to let my pharmacist know that I have a new ID card?
Yes. Your new ID card will include new BIN and PCN information, which is used by pharmacies when you fill a prescription. To ensure the best customer experience, it’s important to let your pharmacist know that you have a new ID card with new pharmacy information.
Do I need to update my mail order account?
If you have an existing account with CVS Caremark® Mail Service Pharmacy, your new BIN and PCN information will automatically be updated in January. There will be no change for you unless your prescription has expired, or there are no refills left on your prescription. These two instances will require you to get a new prescription from your doctor. If don’t have a mail order account, but want to set one up so that you can start getting your prescriptions by mail, then visit sharphealthplan.com/mailorder.
Do I need to do anything if I use a specialty pharmacy?
If you have an existing CVS Specialty™ account, your new BIN and PCN information will automatically be updated in January. If you use a Sharp® Specialty Pharmacy, you will need to share your new member ID card with your pharmacist in January, and let them know that you have new BIN and PCN information. If you have a prescription that is newly considered specialty on the 2020 formulary, you will need to fill your prescriptions through CVS Specialty beginning Jan. 1, 2020 to receive coverage. You can sign up here. Signing up will require your new BIN and PCN information, as well as a new prescription from your doctor.
Will the member reimbursement process change for prescription drugs?
Yes. You will continue to be able to download the request form here. Please note that the form will have a new look and feel. Beginning Jan. 1, 2020, you will need to send your member reimbursement forms to CVS Caremark at PO Box 52136, Phoenix AZ 85072-2136. This contact information will be printed on the request form.
What should I do if I’m going on vacation?
If you have a vacation planned, it’s a good idea to refill your prescriptions before you leave. If you are traveling before Jan.1, 2020, please contact Customer Care at 1-800-359-2002 to request an exception to fill your prescription early. Beginning Jan. 1, 2020, you can call our dedicated prescription helpline at 1-855-298-4252 to request an exception.
Is there anything else I should know?
Beginning Jan. 1, 2020, we’ll offer an improved digital pharmacy experience that will allow you to access pharmacy benefit information through our website and portals. We’ll also offer enhanced digital tools, like the free CVS Caremark mobile app that lets you see your personalized pharmacy benefit information, refill or request new mail service prescriptions, track order status, view prescription history and much more. You can download the app from the Apple and Google Play stores.
Acupuncture and chiropractic care
How can I get acupuncture treatment?
How to get services
If acupuncture services are covered through your benefit plan, search for a provider or call 1-800-678-9133 to speak with an American Specialty Health (ASH) representative for assistance.
How to find out if you have acupuncture services
Log in to your Sharp Connect account to see your Member Handbook and Summary of Benefits to determine if your benefit plan includes coverage for acupuncture services. For more information, please call Customer Care at 1-800-359-2002, or email email@example.com.
Learn more about getting acupuncture care.
How can I get chiropractic care?
If chiropractic services are covered through your benefit plan, search for a provider or call 1-800-678-9133 to speak with an American Specialty Health representative for assistance. No referral from Sharp Health Plan or your primary care physician is required.
How to find out if you have chiropractic coverage
Log in to your Sharp Connect account to see your Member Handbook and summary of benefits to determine if your benefit plan includes coverage for chiropractic services. For more information, please call Customer Care at 1-800-359-2002, or email firstname.lastname@example.org.
Learn more about getting chiropractic care.
Get discounted services
For Members who do not have this coverage (or who may have used all their allotted benefits during the current year), Sharp Health Plan partners with American Specialty Health (ASH) and its affiliate, Healthyroads, Inc., to provide discounts on alternative care services. Receive 25% 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.
Receive 15 to 40% off suggested retail prices on more than 2,400 health and wellness products, including vitamins, minerals, herbal supplements, homeopathic remedies, sports nutrition products, books, DVDs, fitness products and skin care items.
For assistance with ordering wellness products or locating an alternative care provider, please contact our health discounts partner, American Specialty Health at 1-877-335-2746.
How do I cancel my coverage?
If you enrolled in benefits through your employer, please contact your human resources department.
If you purchased insurance directly through Sharp Health Plan, please complete this form, which can also be submitted online through Sharp Connect. You will receive written confirmation once your request has been processed.
If you purchased insurance through Covered California, you must submit the termination form above, and also cancel your benefits by logging into your Covered California account.
Care while traveling outside of the San Diego area
Am I covered when I am outside Sharp Health Plan’s service area?
You are covered for emergency and urgent care when you are outside Sharp Health Plan’s service area (San Diego and southern Riverside Counties). 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 your primary care physician or Sharp Health Plan within 48 hours or at the earliest time reasonably possible. This will allow your doctor to share your medical history with the hospital and help coordinate your care.
How can I get care outside Sharp Health Plan’s service area?
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.
Learn more about getting care outside of San Diego.
Coverage for adult children
How long can my child be enrolled in Sharp Health Plan?
In most cases your child can be enrolled in Sharp Health Plan until the last day of the month of their 26th birthday.
Can my child’s spouse and children enroll in Sharp Health Plan?
No, your child’s spouse and children are not eligible to enroll in Sharp Health Plan under your policy; however, your child’s spouse and children may be eligible to enroll in their own individual/family plan through Sharp Health Plan.
Can my child enroll in Sharp Health Plan if he/she is married?
If your benefit plan is provided by your employer, check with your employer to find out if you can enroll your dependents. If your employer includes coverage for dependents or you have an individual/family plan, your child is eligible for enrollment up to age 26 regardless of marital status.
Coverage for dependents living outside of San Diego
Can I enroll my dependents living outside Sharp Health Plan's service area?
In most cases, all eligible family members must live or work in San Diego County to enroll in Sharp Health Plan.
Can my child who lives outside of San Diego enroll in Sharp Health Plan if I have a medical support order?
Yes, as long as there is a valid medical support order in place. If you are enrolled in an HMO plan, your child will be covered for emergency and urgent care services while outside the plan’s service area. If you are enrolled in a POS plan, your child may obtain care from any licensed provider but the costs using Tier 2 - Aetna/or Out-of-Network benefits will be higher and your child will usually pay a deductible and coinsurance.
Coverage for newborns and newly adopted children
How can I get coverage for my newborn or newly adopted child?
If your benefit plan is provided by your employer, contact your employer’s human resources department for instructions and an enrollment change form to add your newborn. If you are enrolled in an individual/family plan, contact Sharp Health Plan Customer Care at 1-800-359-2002 for instructions and an enrollment change form. An eligible newborn is covered automatically for the birth month, but must be enrolled within 30 days to be covered after the birth month. Adopted children are covered from the date of birth if enrolled within 30 days.
Coverage for spouses and partners
Can my spouse or partner and dependents be covered under Sharp Health Plan?
Yes, if your employer provides coverage for dependents and you are enrolled in Sharp Health Plan or if you are enrolled in an individual/family plan, your legally married spouse or registered domestic partner and your children are eligible. Some employers also cover non-registered domestic partners. Contact your human resources department for more information.
Learn more about adding or removing dependents.
If my spouse loses health coverage through his or her employer, can he or she be covered under my Sharp Health Plan?
In most cases, yes. If you are a Sharp Health Plan Member when your spouse loses group coverage through your spouse’s employer, your spouse may enroll as a dependent under Sharp Health Plan, so long as enrollment occurs within 30 days for large groups and 60 days for small groups and IFP plans from the date that coverage ended under the former health plan.
Learn more about adding or removing dependents.
Can I add or remove my spouse or partner to my Sharp Health Plan coverage if open enrollment is over?
Yes, as long as there has been a qualified family change, such as marriage. Enrollment must occur within 30 days for large groups and 60 days for small groups and IFP plans from the time your dependents first become eligible to join (that is, within the marriage or domestic partnership).
Learn more about qualifying events.
Coverage for students
Does my child have to be a full-time student to enroll in Sharp Health Plan?
If your benefit plan is provided by your employer, check with your employer to find out if you can enroll your dependents. If your employer includes coverage for dependents or you have an individual/family plan, your child is eligible for enrollment up to age 26 regardless of student status.
Can my child who attends school outside of San Diego County enroll in Sharp Health Plan?
Yes, as long as your child retains a permanent residence in Sharp Health Plan’s service area. If you are enrolled in an HMO plan, your child 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. If you are enrolled in a POS plan, your child may obtain care from any licensed provider but the costs using Tier 2 - Aetna/or Out-of-Network benefits will be higher and your child will usually pay a deductible and coinsurance.
Covered benefits — HMO plan
Which services are covered under Sharp Health Plan HMO?
Sharp Health Plan HMO is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services always include coverage for medically necessary 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 the benefit plan you are enrolled in. Log in to Sharp Connect to check your Member handbook, benefit plan matrix and any other supplemental benefit information to find out which services are covered under your plan.
Where can I get a summary of my benefits?
Log in to your Sharp Connect account to view a medical benefits summary, Member Handbook and other plan documents online. If you prefer, you can contact us to have a benefits summary and Member Handbook sent to you.
How do I get authorization for medical care?
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 calling Customer Care at 1-858-499-8300 or 1-800-359-2002.
Covered benefits — POS plan
Where can I get a summary of my benefits?
Log in to your Sharp Connect account to view a medical benefits summary, Member Handbook and other plan documents online. If you prefer, you can contact us to have a benefits summary and Member Handbook sent to you.
Which services are covered under Sharp Health Plan POS?
Sharp Health Plan’s Point of Service Plan (POS) is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services always include coverage for medically necessary 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 the benefit plan you are enrolled in. Log in to Sharp Connect to check your Member Handbook, benefit plan matrix and any other supplemental benefit information to find out which services are covered under your plan.
What is the difference between the POS and HMO plan?
Except for PCP services, emergency services, and obstetric and gynecologic services, you are responsible for obtaining valid authorization before you receive covered benefits at the Tier 1 – HMO Benefit Level. 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. Some Tier 2 - Aetna/or Out-of-Network services require precertification before you receive services.
It is your responsibility to make sure that you receive precertification. Check your benefit summary to find out which services require precertification. If you do not receive required precertification, you may be required to pay 50% of the amount Sharp Health Plan pays the provider for that service rather than the coinsurance amount listed, even if the services are approved as medically necessary. The 50% payment will not count toward your deductible or annual out-of-pocket maximum.
What should I do if I don’t recognize the provider listed on my claim?
It’s possible that a particular medical treatment was performed at an facility unfamiliar to you or outside of your network. Contact your primary care physician, if you have questions about treatments.
Who do I contact if I have questions about my claim?
Contact Customer Care with your specific questions. Please send us a message or call Customer Care at 1-858-499-8300. We're here to help.
How do I request a deductible?
Sharp Health Plan will give you a credit toward your Sharp Health Plan deductible for approved amounts that were applied toward your deductible with your previous health plan (for the same calendar year). Keep in mind, we can’t give you credit for deductible amounts paid for outpatient prescription drugs. To request a deductible:
- Download and send the completed form and the required attachments to Sharp Health Plan within 90 days of the start of your Sharp Health Plan coverage. We will not process Deductible Credit Request Forms received more than 90 days after your start date.
- List the deductible amount met by each family Member separately. You only need to fill out one Deductible Credit Request Form for all family Members covered by Sharp Health Plan.
- Attach a copy (front and back) of the most current explanation of benefits (EOB) from your previous health plan. The EOB must list all deductible amounts you are requesting as credit.
How can I get dental care?
If you have dental coverage through your policy — log in to Sharp Connect to find out — contact our dental care partner, Premier Access Dental. Visit premierlife.com, call 1-888-715-0760 or email email@example.com to find a provider.
If you currently have dental coverage
If your benefit plan includes dental services, call your Premier Access dentist to make an appointment, and let them know you are a Premier Access Dental Member. You will need to provide your ID, date of birth and the covered Member’s ID number. (The covered Member is the eligible employee or family leader who signed up for your insurance coverage. It will be either you, your spouse/domestic partner or your parent.) Once you make your appointment, your dentist and Premier Access Dental will handle the rest.
Emergency and urgent care services
Where and when can I get urgent care services?
Sharp Health Plan has urgent care centers throughout San Diego and southern Riverside Counties. You can search for an urgent care center or call us at 1-800-359-2002. In most cases, you must contact your primary care physician for authorization before going to an urgent care center. Sharp Rees-Stealy (SRS) Members do not need authorization before going to SRS urgent care centers and Sharp Community Medical Group (SCMG) Members do not need authorization before going to an urgent care center affiliated with SCMG. Check the Plan Medical Group on your member ID card.
What if I have an emergency situation?
As a Member, you can visit any emergency room, whether in San Diego or anywhere worldwide. If you are not sure whether your situation is an emergency, call your primary care physician. Your primary care physician can help you decide on the best course of action. You can also talk to a nurse after hours with Sharp Nurse Connection® for medical assistance during evenings and weekends. To talk to a nurse call toll-free at 1-855-995-5004 from 5 p.m. - 8 a.m., M-F, and 24 hours a day on weekends.
How can I get medical advice outside normal office hours?
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 talk to a nurse, call toll-free at 1-855-995-5004 from 5 p.m. - 8 a.m., M-F, and 24 hours a day on weekends.
Getting care outside of San Diego
Can Sharp Health Plan Members get covered care outside of San Diego?
Yes, as a Sharp Health Plan Member, you are covered for urgent care and emergency care wherever you are, although routine care is only covered at home in our service area. If you need help finding urgent or emergency services outside of our service area, our partner, Assist America®, can help. Assist America services are available when Members face a medical emergency while traveling 100 miles or more away from their permanent residence, or when visiting a foreign country. Assist America will immediately connect you to doctors, hospitals, pharmacies and other health care services.
Learn more about how we cover care outside of San Diego.
Explanation of Benefits (EOB)
What is an EOB?
An EOB stands for an Explanation of Benefits. It is not a bill or request for payment. You will receive a separate bill from your provider showing what you are responsible for paying.
What does “allowed amount” mean?
Allowed amount is the maximum amount Sharp Health Plan will pay for a covered health care service.
Why does my claim say “amount you saved”?
This shows discounts negotiated by Sharp Health Plan to save you money.
What is a claim?
A claim is a payment request your provider submits to Sharp Health Plan when you receive services you think are covered.
What is a deductible?
A deductible is the amount you pay for covered health care services before Sharp Health Plan starts to pay.
What is coinsurance?
Coinsurance is a percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
What is a copay?
A copay is a fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
What does “out-of-pocket maximum” mean?
The out-of-pocket maximum is the most you have to pay for covered services in a health plan year including deductibles, copays and coinsurance.
Who is the patient?
A patient is the name of the person for whom services were rendered.
What are the dates of service?
Dates of service show the days you received your medical care.
What is a summary?
The summary highlights your financial information, such as the amount billed, your total benefits approved and the amount you owe.
What is a patient acct?
A patient acct is the number assigned by the service provider.
What’s a CPT code?
CPT stands for Current Procedural Terminology. It is a medical code used to report medical, surgical and diagnostic services.
What does “amount not covered” mean?
The amount not covered is the portion of the claim not covered by your health insurance.
What’s a remark code?
A remark code relates to the charges not covered amount.
What’s a remark code description?
A remark code description is an additional explanation of the remark code. See the explanation of the remark code above.
Over-the-counter (OTC) drugs are medicines sold directly to a consumer without a prescription from a health care professional.
HMO vs. POS
What is the difference between the POS and HMO plan?
In a health maintenance organization (HMO) plan, you must select a primary care physician. Your primary care physician will coordinate all your medical care. All care is typically received by in-network physicians.
In a point-of-service (POS) plan, you choose your primary care physician in network but have the option to go out of network. Going out of network will cost you more.
If hospitalization is necessary, which hospital will I use?
Sharp Health Plan’s network includes many hospitals throughout San Diego. View the full list of hospitals. Primary care physicians (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. Contact us to find out which hospitals are used with your Plan Medical Group, or search for a hospital and narrow your search results by your Plan Medical Group.
Additional information for POS plan Members
If you are a POS Member, you may also obtain care from any licensed provider not affiliated with the Plan Medical Group you selected. Your costs will be higher and you will usually pay a deductible and coinsurance when using Tier 2 - Aetna/or Out-of-Network benefits. To find the Tier 1 - HMO Benefit Level hospital closest to you, use the Find a Doctor or Location tool and select "Hospital, Urgent Care or Facility".
How do I transfer my medical records?
How do I transfer my medical records?
Because Sharp Health Plan is not a medical provider, we do not store or send copies of the medical records of our members. If you are new to Sharp Health Plan, please contact your former PCP to find out how to request and forward a copy of your medical records to your new Sharp Health Plan PCP. Your Sharp Health Plan assigned PCP’s name and telephone number are shown on your member identification (ID) card. Your PCP will provide you with the Medical Records Release form that you will need to fill out to complete the request. This form does not come from Sharp Health Plan. To get information about how to request records from Sharp facilities & providers visit Sharp.com.
What should I do if I do not receive my member ID card?
If you are a new Sharp Health Plan member who registered for benefits either through Covered CA or through Sharp Health Plan directly, you must make your initial payment to Sharp Health Plan in order to be activated in our system. You will receive your new member ID card up to 10 business days after your initial payment has been received. If your plan includes three or more covered family members, those cards will be mailed separately.
If you are enrolled in benefits through an employer-sponsored plan, it can take up to 10 business days after signing-up for benefits through your human resources department to receive your new member ID card.
If you are currently enrolled in benefits with Sharp Health Plan, and recently made a benefit change, made a demographic change (e.g. – changed your name or gender), or selected a new primary care physician (PCP), you will automatically be sent a new member ID card. It can take up to 7 business days after making one of these changes to receive your new member ID card in the mail.
If you lost your member ID card and have requested a replacement, please allow up to 7 business days to receive your new one in the mail. In the meantime, you can print a temporary member ID card through the Sharp Connect member portal.
I received my member ID card in the mail, but other covered family members’ cards were missing. What should I do?
Don’t worry! If your plan includes three or more covered family members, those cards will be mailed separately.
What should I do if the name on my member ID card is incorrect?
If you or one of your dependents received a member ID card with the incorrect personal information on it (like your name), you can request a replacement online by logging into your Sharp Connect member portal. From within the portal, you will be able to review your personal information, update your information if necessary, and request a new member ID card.
What should I do if the primary care physician listed on my member ID card is incorrect?
If you receive a member ID card with the wrong primary care physician (PCP) listed on the front, please log into your Sharp Connect member portal to verify the PCP that we have on record for you. Please note that if you are a Sharp Rees-Stealy member, your ID card will not list your PCP’s name, only the location of the Sharp Rees-Stealy Medical Center where they see patients. We know choosing the right PCP is a personal decision, which is why we make it easy for you to change your selection at any time. Please visit sharphealthplan.com/findadoctor to find a list of doctors. Once you’ve made your selection, you can update your PCP through the member portal. Please note that PCP changes will be effective the first of the following month. Upon making your selection, we will mail you a new member ID card.
When do I need to start using my member ID card?
Your member ID card is your key to accessing care and filling prescriptions. Please carry it with you at all times and present it whenever getting care.
What will my member ID card look like?
The front of your member ID card will include your name, date of birth, account information, primary care physician’s name or affiliated medical group location, medical deductible (if applicable) and certain cost share information. The back of your new card will include important contact information. If you’ve purchased pediatric dental coverage, you’ll also see that noted on the back of your card. To see samples of what the ID cards look like, view or print this downloadable PDF. If you are a CalPERS employee, view or print this CalPERS member ID PDF.
What should I do if my member ID card shows the wrong effective date?
The effective date on your ID card does not affect your ability to access care or fill prescriptions. The effective date listed on the ID card is based on contract updates in the Sharp Health Plan system. If you enrolled in Sharp Health Plan before 1/1/16, your ID card will list that effective date. If you enrolled after 1/1/16, you will have a later effective date.
I made an initial payment, but I haven't received my member ID card. Am I still covered?
Please allow up to 10 business days after making your initial payment to receive your member ID card. If it has been more than 10 business days since you made your payment, please contact Customer Care.
What should I do if I have not received my new member welcome kit?
Your new member kit will be mailed to you within 10 business days of activating your enrollment with Sharp Health Plan. If you are a new member who applied for coverage directly through Sharp Health Plan or Covered California (and not your employer), you must make your initial premium payment to Sharp Health Plan to become effective as a member. Once your initial premium payment has been posted in our system, which can take up to 3 business days, we will mail your new member ID card(s) and a welcome kit.
If it has been more than 10 business days since you enrolled (and made your initial payment if applicable), and you still have not received your welcome kit, please email firstname.lastname@example.org. Please note if you did receive your ID card(s) but not your welcome kit, you can register for our member portal, Sharp Connect. There you can check benefits, copays, coverage status, change your primary care physician (PCP), print a temporary member ID card, and access health and wellness information. Visit sharphealthplan.com/login to register and have your member ID number available. This number is in the upper right-hand corner of your new card.
Who do I contact with questions?
If you have questions, please contact Customer Care at email@example.com, 1-858-499-8300, or toll-free at 1-800-359-2002. We are available to assist you Monday through Friday from 8 a.m. to 6 p.m.
IRS 1095 tax forms
Who will issue a 1095 form to me?
Sharp Health Plan will send you a 1095-B form if you were enrolled in the Plan through your employer or directly through Sharp Health Plan in 2018. You may receive different forms if you had changes in health coverage during 2018.
If you enrolled in Sharp Health Plan through Covered California, you will receive Form 1095-A from Covered California.
I had coverage through Medicare, and was enrolled in Sharp Direct Advantage. What form will I get so I can show I had coverage?
You will get Form 1095-B from Medicare, the Centers for Medicare & Medicaid Services (CMS).
What if I changed employers or health insurance plans during 2018?
You may receive more than one 1095 form if you had health care coverage from more than one health insurance plan during 2018.
What information is included on the 1095-B form?
The 1095-B form includes the names and Social Security Numbers (SSNs) or dates of birth for members enrolled in Sharp Health Plan during 2018. It also identifies the months of coverage for each individual listed. To ensure that our members’ personal information is protected, the 1095-B form includes only the last four digits of the SSN.
When will Sharp Health Plan issue 1095-B forms?
Sharp Health Plan will mail 1095-B forms to subscribers by March 4, 2019.
What should I do if I did not receive a 1095-B form?
If you were enrolled in Sharp Health Plan during 2018, but you do not receive a 1095-B form by January 31, 2019, please contact Customer Care at firstname.lastname@example.org or 1-800-359-2002.
If you were enrolled in Sharp Health Plan through Covered California and did not receive a 1095-A form, please contact Covered California at 1-800-300-1506.
If you were enrolled in a Medicare Sharp Direct Advantage plan, please call 1.800.Medicare or visit their website at Medicare.gov.
What should I do with the 1095 form(s)?
The 1095 form is verification that you had minimum essential health coverage during 2018. You do not need to submit the form with your tax filing. Please consult your tax adviser and refer to the IRS website for information about the use of the 1095 form.
What should I do if I receive an incorrect 1095 form?
If you received a 1095-B form from Sharp Health Plan that you believe is incorrect, please contact Customer Care at email@example.com or 1-800-359-2002.
If you received a 1095-A form from Covered California that you believe is incorrect, please contact Covered California at 1-800-300-1506 or go to the website at Covered California.
What if I have a question about the 1095 form(s) I receive?
If you have questions, contact the issuer at the phone number or email address printed on the form. In addition, we encourage you to consult your tax advisor and refer to the IRS website for guidance.
Medical bills and reimbursements
What if I get a bill for medical services?
As a Sharp Health Plan Member, you will not normally receive a bill from a provider unless you have not paid your copay or deductible. 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. Contact Customer Care at 1-800-359-2002 as soon as possible and explain the situation. We will work with the provider to have the bill sent to Sharp Health Plan.
How can I request reimbursement for medical expenses that I have paid?
If you receive emergency or urgent care services outside of San Diego County, you may be asked to pay for those services. If that occurs, you can request reimbursement from Sharp Health Plan.
Learn how to request a reimbursement.
How can I request reimbursement for prescription drugs that I paid for?
In some cases, you may be asked to pay for prescription drugs that are normally covered by Sharp Health Plan. An example is when you are traveling outside of California and urgently need to fill a prescription. You can request reimbursement for covered prescription drugs from us. 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.
Mental health services
Which mental health services are covered?
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 log in to your account to view your Member Handbook and benefits summary.
How do I get mental health services?
As a Member, you can get mental health services without a referral from your primary care physician. Please call Psychiatric Centers at San Diego toll-free at 1-877-257-7273 whenever you need mental health services. You can visit sharphealthplan.com to learn more about care for mental health.
Networks vs. medical groups
What is a Plan Medical Group (PMG)?
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 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 part of the Independent PMG.
You receive covered benefits from doctors who are affiliated with your PMG and who are part of your Plan Network. In most cases, each PMG includes a different set of PCPs, specialists, urgent care centers and other providers. In addition, your selection may impact the primary hospital in which services are delivered. 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 at 1-800-359-2002.
What is a Plan Network?
A Plan Network is the group of doctors, medical groups and hospitals available to you as a Sharp Health Plan Member. There are four Plan Networks: Choice, Value, Performance and Premier. You select your PCP and Plan Medical Group from the Plan Network you are assigned. You will find the name of your Plan Network on your member ID card.
Our networks explained
What is the Performance Network?
Performance is one of Sharp Health Plan’s Plan Networks. The Performance network includes Sharp Community Medical Group (SCMG), Sharp Rees-Stealy Medical Group, Rady Children’s Health Network/CPMG, SCMG Graybill Medical Group, SCMG Inland North Medical Group, and SCMG Arch Health Partners. You will find the name of your Plan Network on your Member ID card.
What is the Premier Network?
Premier is one of Sharp Health Plan’s Plan Networks. The Premier network includes Sharp Community Medical Group and Sharp Rees-Stealy Medical Group. You will find the name of your Plan Network on your member ID card.
Our service area
What is Sharp Health Plan’s service area?
Sharp Health Plan is San Diego’s only non-profit locally based commercial health plan. We serve employers and individuals based in San Diego and southern Riverside Counties. Use our helpful tool to check if your ZIP code is included in Sharp Health Plan’s service area.
Sharp Health Plan connects members to thousands of physicians and 13 local hospitals through four networks: Choice, Value, Performance and Premier. Learn more about our networks and their coverage area.
Search for a doctor to determine if a specific physician is part of Sharp Health Plan’s provider network.
Physical, speech, and occupational therapy
Am I covered for physical therapy, speech therapy or occupational therapy?
All Sharp Health Plan Members are covered for outpatient and inpatient rehabilitation services, including occupational, physical and speech therapy. Services must be medically necessary and will be reviewed periodically to determine if continued therapy is needed.
Do I need a referral and copay?
Ask your primary care physician about referral to an appropriate specialist for therapy services. The Member’s share of cost for therapy services could be deductible, copay and/or coinsurance for each therapy visit. The copayment amount is listed on the benefits summary available by logging in to Sharp Connect or by calling Customer Care at 1-800-359-2002, or emailing firstname.lastname@example.org.
Information for POS plan Members
Ask your primary care physician about referral to an appropriate specialist for therapy services at the Tier 1 — HMO Benefit Level. You may also obtain care from any licensed provider not affiliated with the Plan Medical Group you selected. Your costs will be higher and you will usually pay a deductible and coinsurance when using Tier 2 - Aetna/or Out-of-Network benefits.
Primary care physicians (PCP)
What is a primary care physician (PCP)?
A primary care physician (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.
How do I choose a primary care physician (PCP)?
We encourage you to select a primary care physician (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 you can access care immediately. For the most up-to-date information on available PCPs, call Customer Care at 1-800-359-2002.
Can I choose a different primary care physician (PCP) for different Members of my family?
Yes, each covered family Member may choose a different primary care physician (PCP) from a different Plan Medical Group. All family Members must stay in the same Plan Network.
Can I change my primary care physician (PCP)?
Yes, in general it is a good idea to stay with a primary care physician (PCP) so he or she 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 Sharp Connect to use the online Change PCP Form, or you can call Customer Care at 1-800-359-2002 and we will help you select a new PCP. The change will be effective on the first day of the following month.
How does Sharp Health Plan protect my privacy?
We understand the importance of keeping your personal information confidential and work to ensure that all privacy regulations are followed. The Health Insurance Portability and Accountability Act’s (HIPAA) privacy regulations govern the use and release of a Member’s personal health information, also known as protected health information (PHI).
Under the HIPAA privacy regulations, Members must be informed about how their PHI will be used and given the opportunity to object to or restrict the use or release of their information. You can find a copy of Sharp Health Plan’s Notice of Privacy Practices here and in the Member Handbook.
What is a specialist?
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 primary care physician (PCP) will refer you to a specialist to ensure that you receive proper medical attention and follow-up. Your PCP will refer you to a specialist in your Plan Medical Group (PMG). In most cases, each PMG includes a different set of PCPs, specialists, urgent care centers and other providers.
Does my primary care physician (PCP) make the decision about which specialist I see, or am I able to make that decision?
Your primary care physician (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 can see 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 how to see a specialist, call Customer Care at 1-800-359-2002.
Understanding open enrollment with Covered California
How do you know if you need to change your health plan? What should you consider?
You can change your health plan during the open enrollment period, October 15 to January 31. There are two common reasons why you may choose to change your plan:
- You are planning to access care more frequently throughout the year. In this instance, you may want to switch to a Platinum or Gold plan where you pay a higher monthly premium, but have a lower deductible and lower copays for medical care.
- You want to change your plan network (Premier Network or Performance Network) to visit a particular doctor. Learn more about Sharp Health Plan’s networks under "Compare networks and plans."
To change your plan, you should log in to your account on CoveredCA.com or call them directly at 1-800-300-1506.
What is open enrollment? When does it take place in and what are the deadlines? If you want coverage for January 1, when must you have a plan in place?
Open enrollment is a period of time each year when you have the opportunity to enroll in health insurance or make changes to your current plan. Open enrollment for the individual and family (IFP) market starts on October 15 and ends on January 31. You must apply by December 15 to have coverage effective on January 1. The open enrollment window is the only time of year when you can enroll in health insurance unless you have a qualifying event such as having a new baby, getting married or losing coverage through your work.
Who should take part in open enrollment -- those without insurance, with insurance, or both?
Whether you have insurance or not, it’s wise to participate in open enrollment to explore your options. If you don’t have coverage, you could be assessed a tax penalty for not carrying health insurance. Even if you do have coverage, it’s an opportunity to review available options to make sure they still meet the needs of you and your family. Open enrollment is the only time that changes can be made unless a qualifying event occurs.
For those who've not had insurance before, do you have any advice on what to look for or consider when picking a plan? Where do you go to get started with comparing plans?
Whether you are shopping for insurance for the first time or renewing your policy, the most important advice is to find a high-quality health plan at the best value. Many individuals don’t realize that there’s a difference in quality ratings between health plans. Covered California uses Members’ experiences to rate the quality of its participating health plans. Their rating system has one to four stars, with four stars being the top rating. Also, the National Committee for Quality Assurance (NCQA) has different levels of accreditation status for health plans. NCQA awards its highest accreditation status of Excellent to health plans that meet or exceed rigorous requirements for quality improvement.
To review the benefit plan options that are available, you can search plans on CoveredCA.com using their “Preview Plans” tool. This tool allows you to preview plans and prices from multiple insurance companies and tells you whether you may qualify for government subsidies to help pay for health insurance. Or, you can shop the specific plans offered by a particular insurance company using its website. Either way, you can do it on your own, or get help from a licensed insurance broker.
Although insurance companies differ in quality ratings, those who participate in Covered California offer the exact same benefit designs arranged in four categories or metal tiers (Bronze, Silver, Gold and Platinum). Platinum plans have the highest monthly premiums, but the lowest costs when accessing care. Bronze plans have the lowest monthly premiums, and the highest costs when accessing care. Gold and Silver plans strike a balance between the two. For example, if you are healthy and only visit the doctor once a year, you may benefit from a Silver or Bronze plan that carries a lower monthly premium but higher out-of-pocket costs when accessing care. If you see your doctor more frequently, then you may consider a Platinum or Gold plan.
Lastly, make sure your doctor or specialist (if you have one) participates in the provider network of the health plan that you select.
For those who are already insured and happy with their current plan, what - if anything - do they need to do during open enrollment, especially if they get insurance through their employer?
Even if you are insured and happy, it’s always a good idea to review your health coverage options each year. Health insurance benefits will sometimes change from one year to the next.
What about those who get insurance through the healthcare marketplace? What should they do during open enrollment to make sure their coverage continues?
Insurance companies with Covered California will send renewal notices highlighting benefit and rate changes for the coming year. If you want to make changes to your plan or switch insurance companies, you’ll need to do so by December 15 for a January 1 effective date. Because rates and plans tend to change annually, you will want to review which options are best for you and your family. If you purchased coverage through Covered California, it’s important to update any income changes that may affect subsidies for health insurance as this could impact your taxes. In the meantime, keep paying your monthly bill to make sure your current coverage continues.
Please note if you have employer-sponsored coverage, you would not be eligible for a premium subsidy through Covered CA.
How can I get vision care?
Log in to Sharp Connect or contact us to find out if your benefit plan includes coverage for vision services.
If you currently have vision coverage
If your benefit plan includes vision services, call your Vision Service Plan (VSP) doctor and make an appointment, letting the doctor know that you are a VSP Member. You will also need to provide your ID, date of birth and the covered Member’s identification number. (The covered Member is the eligible employee or family leader who signed up for your insurance coverage; it will be either you, your spouse/domestic partner or your parent.) Once you make your appointment, your doctor and VSP will handle the rest.
Getting services from a non-VSP provider
In some cases, you may also select to receive services from a non-VSP provider and VSP will reimburse you for part of the cost. Any service you get from a non-VSP provider is subject to the same copayments and limitations as services obtained through VSP doctors. Be aware that your out-of-network provider reimbursement rate does not guarantee full payment, and VSP cannot guarantee patient satisfaction when services are received from a non-VSP provider. You may be required to pay the entire bill when you see the non-VSP provider. Call VSP Member Services at 1-800-877-7195 to find out if your coverage includes non-VSP providers.
Are the Sharp Health Plan wellness programs covered under my plan?
As a Member, you get 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 can get health coaching program and can work one-on-one with a coach to reach personal health goals. See the Health & Wellness center for more information.
Are my dependents eligible for the wellness programs?
Yes, your enrolled dependents are eligible for the Sharp Health Plan wellness programs.
How can I get information about alternative health care programs?
The alternative health care programs from Sharp Health Plan offer you discounts of up to 25% 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 15-40% 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, DVDs, fitness products and skin care items.
You can find more information on these services here or by calling 1-877-335-2746.
Does Sharp Health Plan provide any wellness programs?
As a Member, you get comprehensive resources through our nationally accredited Best Health™ wellness program. You can take a wellness assessment, get a wellness score and report, enjoy multi-week wellness programs on various health topics, and much more. You can even take advantage of our health coaching program and work one-on-one with a coach to reach your personal health goals. Visit the Prevention and Wellness Center for more information.
Women’s health services
What kind of women’s health services do you cover?
From well woman exams to breast cancer screenings and pregnancy care to one-on-one health coaching, Sharp Health Plan connects you to the best women’s health services. Your specific coverage depends on your benefit plan; log in to Sharp Connect to see your coverage details.
Learn more about our women’s health services.
Am I covered for infertility services?
Depending on your plan, you might have coverage for the diagnosis and treatment of infertility and/or coverage for Assisted Reproductive Technologies (ART). These services may include artificial insemination, IVF or GIFT, and are determined based on your specific benefit plan.
If your benefit plan includes coverage for infertility services, ask your primary care physician about a referral to an appropriate specialist for infertility diagnosis and treatment. Members pay a copayment equal to 50% of the contracted rate for all infertility and artificial reproductive technology services.
Where can I find out about my plan’s infertility care coverage details?
How to find out if you have infertility service coverage
Check your Member handbook and summary of benefits to determine if your benefit plan includes coverage for infertility diagnosis and treatment. Log in to Sharp Connect or contact us to find out if your benefit plan includes coverage for infertility treatment or reproductive technologies.
Information for POS plan Members
Infertility services (the diagnosis and treatment of the underlying condition) are only covered on the Tier 1: HMO Benefit Level and not on the Tier 2: Aetna/or Out-of-Network Level.
Are breast pumps a covered benefit?
Most Members are covered for a breast pump with no copayment, if requested within 365 days after delivery. (Breast pumps are not covered prior to delivery.) Your OB/Gyn can provide you with a referral for a breast pump. Call us at 1-800-359-2002 or email email@example.com for information on how to order a breast pump. Breast pumps are not covered if purchased from a non-contracted supplier.
Learn more about pregnancy care.